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San Joaquin County Environmental Health Department <br /> DATEGREEN FORM <br /> �l d MASTER FIIL,E RECORD INFORMATION "MFR" A� T `, <br /> e1MOEnMFAS FOR ENDUSE ONlr 1"Ist IDS T14S CiABER Ur\' 1 <br /> 1• OWNERFIIE <br /> COMPLETE nfEFou on7NG PROPERTY OWNER/NFORMAnom Onm fr OWNER cvwxam.rwvra.ermrr END <br /> PROPfRry DasNEa NAI,E rl PNONE T-oCj 31 — X14 Ji{ <br /> FLnY ul Last <br /> BusuumltlA tt SOOSEO/TMIDa <br /> it U reie <br /> Owner Moms Address OOCcr DArvER's LICENsrs <br /> O Y f 8 <br /> City ; STATE C 1 Zip �S!SO <br /> owearlaalnntlAddraaa LC? Via v a - l••Il y <br /> MaDng Addrem City sa ` slob t Zip 953 S 4. <br /> CORPO 13 MONIDUAL❑ PAmRencuW0 FEDAGENCY❑ OTHER <br /> FACILITY FILE <br /> FACILITVIDS aTaa CROns REF to AGOOONT IDA <br /> Co PLErE rHEFOL LWAiG 8U S I N E S S I FACILITYI SITE/NFORMATichil- <br /> Isth is a NEW Business LocAnoit not previously regulated by the ENVIRONMENTAL HEALTH DEFT.? YEs No ❑ <br /> Is this an EmsnNG Business LOCATION but a NEW TYPE of regulated Business? Yes ❑ No ❑ <br /> BussesNFAcoLnyfsnEr W p - ' <br /> $HEADDRESS X/1� 1 /�r. D,CJS sunER BUSINEESSP E <br /> GirtL <br /> l I+li t/l/Tr 1/ $TATE/)^ ZIP 7S- N <br /> BOARD Or S.5- <br /> 1 Kai KEY2 <br /> Mailing AEbau MO0FEHENT#VMFFC#9yAdapea Attention:or Care Of(opGarai# <br /> MaiOrsg Addraas CBy STATE Zm <br /> SIC Go" ( APNs Cc uwl uy; <br /> l <br /> TBIeD PAKry BiLume INFO: Complete dBilling Party is different from Property Owner orFacility Operator identified above. <br /> BUSNESS NAME 14d (I Attention:xCare Of(ophorull <br /> C I+L 4 i 0A r, s t <br /> M.Dirq Addrw .ZN$r`J !�J-�.., ;, -_. ,.,.s la,rk. :.+� S� Oo <br /> crrr STATE C/` Zw et5 3 3 <br /> Ag2agjApOW forfeea and charges OWNER FACILITY/BusfmEss TmRD PARTY BILLING <br /> BILLVSGANDC M?LIANCEACQGVVLEWWlVNr1.Iheundenigned Applicant certifythat l new the(hvnn,ODermnr,orAxt��r,;ed Agent or this Business,eml lacWwwkd,that all PE0ea F6Eg <br /> DF.YILYF£i EN£OACENE'.TC'nAArFI Nnd/or L/OriaLl('HaR<ES associaleA with Ih'a operalinn will be billed to me al IM1e aJdrert itleniifie[I above v ihed(YMPTA�V�wee for thin rite. I alro certify that <br /> all information prarided on this application N true and correct;and that all regulated aetivifica will be performed in ateordance with all applicable SAA JOAQDLN CoLwr a Ordinance Coles and/or <br /> Standards and SAT..and/or VEDEML Laws and Regulation,.As the undersigned owner,opaataq or agent of the property loealed at the above hedityhite address,l hereby authorize the rekaae of <br /> any and all remlD and environmental aineaammt informarioo to SAN JOAQUIN COUNTY ENVFRONMEYtC11, <br /> . IIFILTM nFPM/M,F.N �.i-s- <br /> a-r-a^ila7.hk.�and al the same lime it is <br /> provedmmeormyrepreftoaw6 <br /> APPLICANT NAME SIGNATURE T <br /> hh �C <br /> Q <br /> TTREDRIVER'6 LICENSE a <br /> Tr O "4 s2. (pnor Pc REOWREDl <br /> Approuad by pato W Accounun Omco Drocesaing Completed sly Date O O <br /> 29-02 10/17/07 MAS ITR FILE RF.COMMEEN <br />