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San Jo uuin County Environmental Health #artment <br /> DATE ZD MASTER FILE RECORD INFORMATION "MFR" GREEN FORM <br /> HADEO AREAS FOR EHD USE ONLY OWNER ID# r AO'1 2- CASE# UNIT IV <br /> e C N Q�,rc�.;'Tr �}: VI <br /> OWNER FILE <br /> COMPLETE rHEFOLLO INGPROPERTY OWNER/NFORmArlom CHEcmiF OWNER CURRENTLY0NF7LEWrH EHD ❑ <br /> PROPERTYOwNFRNAME (•_Irp• xJl c �C'N ) 2-It`-14?^57MO Z 4 v 7t� PHONE <br /> v <br /> First MI Last <br /> BUSINESS NAME Hat,, <br /> SOC SEC 1 TAX ID# <br /> Owner Home Address 3i1 S. Mata "'' 4t-t-F r 54-c�-t— ,9s=--2- 9aGN) 0 RIVER'S LICENSE# <br /> C <br /> City &GoN �7. $ h�o� f l�W�uLt Y�I W STATE CA ZIP <br /> Owner Malling Address 5.0.Wt a 0's V%�Qme-v Itiu At .�alo e�.S <br /> MallingAddressClty State Zip <br /> CORPORATION❑ INDIVIDUAL❑ PARTNERSHIP❑ FED AGENCY❑ OTHER 1W <br /> FACILITY FILE <br /> FACILITY ID# ��,��� CROSSREFID# ACCOUNTID# KW31- S Z INV# <br /> COMPLETE THEFOLLowlNG BUSINESS/FACILITY I SITE/NFORMA77o f W <br /> Is this a NEW Business LocATIoN not previously regulated by the ENVIRONMENTAL HEALTH DEPT.? YES No ❑ <br /> Is this an EXISTING Business LOCATION but a NEWTYPE Df regulated Business? YES ❑ No <br /> BUS IN ESS/FAciLrry/SITE NAME <br /> SITEADDRES8 �~ 3 SUITE# BUSINESSPHONE <br /> CITY S'TrC�-twA /V / STATE 7j <br /> BOARDOFSUPERVISOR DISTRICT LOCATIONCODE Kell <br /> KEY2 <br /> Malling Address/fD/FFERENTfi omfac/l/lyAddrv" Attention:or Care Of(opftneq <br /> Melling Address City STATE ZIP <br /> SICCODE �LAPN#`-12q 010 S/ COMMENT: <br /> N /vl Ciro <br /> THIRD PARTY BILLING INFO. Complete ifBilling Party is different from Property Owner or Facility Operator identibedabove. <br /> BustNEssNAME l-`ultyy.c,A r T�II�r a v5 Attention:orCareOf(opb6ml) 270 C <br /> Melling Address 212-1 lJ+�.ut.vcs ,,/Q, f „_I PHONE 11� <br /> Cay �✓� STATE -4 ZIP <br /> AawuATA for fees and charges OWNER FACILITY/BUSINESS THIRD PARTY(BILLING <br /> BILLING AND COMPLIANCE ACKNOWLEDCNIENT: I,the undersigned Applicant,certify that I am the Owner,Operator,or Authorized Agent of this Business,and 1 acknowledge that all PERiHTFEES, <br /> PENALnEs,ENFORCEMENT CHARGES and/or HOORLYCHARGES associated with this operation will be billed tome at the address identified above as the ACcouATADDAESS for this site. I also certify that <br /> all information provided on this application is true and correct;and that all regulated activities will be performed in accordance with all applicable SAN JOAQUIN COUNTY Ordinance Codes and/or <br /> Standards and STATE and/or FEDERAL Laws and Regulations. As the undersigned owner,operator,or agent of the property located at the above facility/site address,I hereby authorize the release of <br /> any and all results and environmental assessment information to SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my representative. <br /> APPLICANT NAME �tC G PLEASE PRINT e G SIGNATOR <br /> TITLE A k DRIVER'S LICENSE# L� <br /> {PHOTOCOPYREOUIREDI �� T <br /> Approved By Date Accounting Office Processing Compteted By Data <br /> 29-02 10/12/07 MASTER FILE RECORD-GREEN <br />