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P San Joaquin County Environmental Health Dortment <br /> DATE ( l as D'8 "'MFR" <br /> EE GREEN FORM <br /> MASTER FIL^E RECORD INFORMATION MFR <br /> <xc c.srmPun rax OWNER ID# /` ��� CASE# UNIT IV <br /> •J OWNER FILE <br /> COMPLETE rt7E FOLLOWINOPROPERTY OWNERrNFORMA770N,' THnOrrr OWNER CURREMIYONPIIEHWH EHD <br /> PROPERTYOwNERNAlur '' `01� Al PHONE ./s�( /I. �C, <br /> fi MI Last l.! 16 __`_) <br /> BUSINESS NAME SOC SEC/TAX ID# <br /> i <br /> Owner Home Address 1 O I a� DRIVER'S lJcXNSE# <br /> City 1 t— Sl <br /> Owner Mailing Address <br /> Mailing Address City $late Zip <br /> CORM TION❑ INDIVIDUAL El PARTNERSHIP EJ FED AGENCY❑ OTNER❑ <br /> _ <br /> FACILITY FILE <br /> FACILITY ID 4 19"-M CROSS REE ID# I ACCOU riD# ��'7 I 1 / NY# <br /> )p <br /> OMPL NFORMA77 <br /> Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT7 YES ❑ No ly <br /> Is this an EXISTING Business LOCATION but a NEW TYPE of regulated Business? yes ❑ No } <br /> BUSINEM/FAaIRY//7S♦tray NAME I�(^"y <br /> $iIEADDRESS -46'6' RE# BUSINESS PHONE <br /> �/ //-��-L - i\-- $UBUSINPHONE <br /> CITY i <br /> CSTATE /_"/-.. ZIP L+ <br /> BDARDOF SVPERV150RDISfRTCf LDCATTDN CODE KEYS REY2 1 J <br /> Mailing Addrt ifDIFFERENrfmnr FacilityAddtess Attention:or Care Of(optional) <br /> Mailing Address City STATE 21P <br /> $IC CODE APN# COMMFM: <br /> THIRD PARTY BILLING.INNFO: Completed Billing Party isdi/ferentbom Property Owner or Facility Operator identified above. <br /> BUSINESSNAME ' —F— AltEdien:OrCaM of /A9/) <br /> 111Y <br /> Mailitq Addd/rne'ss�J L.1, /]-1�� /'/( PHONE �7GJ�.c/a^�c�Cj �r��� I.t� <br /> CRY `/r?i+U_/ \C�•i\ ` Cr 4 STATE z"' -( (�r 6 V I <br /> Alam rADDRIMS for fees and charges OWNER FACILITY/BUSINESS THIRD PART/BILLING <br /> nn I ING axn Cos r svr"n�Mmc m cwPAT: h Dm Undersigned Applicant,certify that 1 am the O).wer.Opem/nr,or Aalhodeedagenlurtho Business,and 1 Acknowledge that all PE/tU)r FEES. <br /> PENALRES,EVRIA4 h mt+T 0LIR6tV n hl/or 11041vPCHARGES associated with this operation will be billed to meat the address idemirted above as the AtY'msTAnnRFvs for This site. 1 also ceraf v that <br /> all information pmvided on this application is true and correrl;and that all regulated actisitim will he performed in accordance with all applicable SAN JOAQUIN COUMY Ordinance Codes and/or <br /> Standards and STATE and/orFEDERAL Laws nad Regulations. :,the undersigned an net,operator.or agent of the properh located at the Also 'IitWsi"atir I hereby authorke the release of <br /> .nty and nil results and ensiromnoHol assessmem information to SAS.10%QVIP'COV\T"ENVIRON)lU\'IAL IWAL'fll ME:; as on as U U acai a and aT Nr sante timc ie is <br /> pnn'idnl to me or nn'representative. <br /> APPLICANT NAMESIGNATURE <br /> CAN,` fir- J <br /> TITLEI "1 �. DRIVER'S/ICEISE# <br /> 1 B+NORDE OPY REWIRED) <br /> Apptosed By 41.4_ Date Accountlml OKNe Processing Completed By Date <br /> C� <br /> 2902-002 %m125.2001 <br />