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.::San iloa uirLCou_nty z'. Health Services, ErtViroriinenit�ea_kh_Division � <br /> DATEGREEN FORM <br /> MASTER FILE RECORD INFORMATION t'MFR" <br /> 'Sawn AarAs raa EMDmw.r 'tea �.�t.}`-�i''rY-. <br /> UNIT IV <br /> OVMER FILE <br /> OMPLETE THE FOLLOWING PROPERTY OWNER INFORMATION; CHEarF OWNER CTntR YONFIAEw EHD ❑ <br /> PROnERWOWNER Sob Franco PHONE (209) /cG - S'Z2S <br /> NAME A,-".C/ <br /> p- o L ezD 9J 9166 - y9s3 <br /> Fist MI sat <br /> RUSENESS NAME SOCSEO/Tax ID# <br /> Owner Home Addrivo; 7Y0G '+/Dods:do DRrvER's Ltx1sE# <br /> 0'3r- <br /> ST0 ckTon srAn 95207 <br /> GA 95,103 <br /> wlRas Atldr� <br /> Gflingess city LP <br /> ❑ FNDrytwU ■ PA ElL9no❑ F®AGENCN•❑ ��❑ <br /> FACILITY FILE <br /> Atsltrm � : AReE '->s, 5._ <br /> COMPLETE THEFOLLOWING BUSINESS FACILITY SITE INFORMATION; <br /> this a New Business LOCATION not previously regulabed by the ENYMONMcwr HEALTH DIVISION? YES ® No ❑ <br /> this an EwhTnw Business LOCATION but a NEW TYPe Of regulated Business? YES ❑ No ❑ <br /> BtlstNEm/FAQIIrY/SIZE NAME <br /> 61,450'. A e k ernDcrT,rS <br /> ADDRESS Sarre# BtISDIESaPNONE (209) t37—Y71 <br /> 61oc k lcc, loxCc(;Po—' SlrceT r eT <rreeT 5o^ara 5T eeT <br /> T STATE Zm <br /> STOC�CTo+1 CA 95203 <br /> �_ <br /> BOARD OFSwatvtsoa DASTRIR -s. -LOCATI[YI xti'�,,-.i- .c,' .- <br /> ailing Address ifDIFFERENT/rom Fac ifyAddtess Atterttion.or Care Of(opdona/) <br /> 'Ty of STo c.�ron /ledc ve% net "T .4i P v 70 1�. c-/ o .da A .,A ZOO C/o /)-5. K.j%a U1111-er <br /> Mailing Address City STATE Zn' ' <br /> STockTon ChF IRD 95ZOZ <br /> PARTY BILLING INFOi Complete if Billing Party is different hon Property Owner or Facility Operator ide76fied above. <br /> ESS NAME Attention:or Care Of (op6DtsaO <br /> nae Tw;..rN �abo/vTorfcs � <br /> ing Address PHOS .765" <br /> 702/ <br /> .2527 Fresno STreeT C559) <br /> Mail <br /> fres no �CA 9372/ <br /> for fees and charges OWNER FACILITY/BUSINESS HIRD PARTY BILLING <br /> BILLING AND COMPLIANL'E ACKNOWLEDGMENT: 1,the undersigned Applicant.certify that I am the Owner,Opermor,or Authorized Agmt of this Bnsinrss,sod I acknowledge that all PERwr FEET, <br /> PEVALnet,£NFORCENE\TC'NAAGEt and/or HOURLY CHARGES associated with this operation"ill be billed to me at the address identified above as the 1C 011TADDAETS for this site. 1 also<ertift that A <br /> ormatian provided o0 this app9c2don Is Due and correct and that all regulated activities will be performed in accordance with all applicable SAV JOAQM COUNTY Ordinance Codes and/or <br /> ndaL M d STATE aod/ar FYDER.V.Laws and Regulations. As the undersigned owner,operator,or agent of the property located at the above,�[['. ) t orize the release of <br /> y and all rnulb and environmental assessment information ro SAN JOAQUIN COUNTY ENVIRONMENTAL HE;,ILTH DIVISION as s�onlr>• '�tla{�.a�y�e It is prv.ided to <br /> me or my representative. 11VV.- U L <br /> f',,/ /1 is E PRINT <br /> IPPLICANT NAME A l'✓G /f�/,/AIQGp pt, SIGNATURE <br /> TITLE 6L7 C/. // DRIVER'S LI FNED) <br /> � - -Date •; `tAgoouMirg Olnoa PiocessitNnIb"rii <br />