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San Joaquin County Environmental Health Department GREEN FORM <br /> DATEGRI )aoca7 MASTER FILE RECORD INFORMATION "MFR'"' <br /> �5�5 CASE# <br /> DWNER ID# UNIT IV <br /> OWNER FILE <br /> CHECRIF OWNER[URRENR.YON FILEWITH EHD <br /> COMGLETETNE FOLLOWING PROPERTY OWNER INFORMATION: n PHONE Cps S�oS" <br /> pROPERTYOWNERNAME <br /> E First MI ast <br /> /. SlK$EC/TAX ID# <br /> BusINESS NAME /.ras CV\C\ t A <br /> C C v O DRMR'S LICENSE# <br /> Owner Home Address A <br /> I STATE ZIP f <br /> city so lar a'-s, J <br /> Owner Mailing Address a <br /> State ZIP <br /> Mailing Address City <br /> rn FED AGENCY OTHER E3 <br /> CORPORATION INDMDUAL� PARTNERSHID� <br /> FACILITY FILE ��j—/,�7(ry(/�, <br /> ✓ _' V "'� INV# <br /> P'�'� I CI IREF ID# ACCOUM ID# �Y <br /> FACILITY ID# O <br /> MF ETE FOLL YES No <br /> NG <br /> FORMA N' <br /> Is this a NEw Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? C] <br /> YES El ND <br /> Is this an EXISTING Business LOCATION but a NEW TYPE of regulated Business? <br /> BUSINESS A M NAME P G E S I.LL� O✓�' <br /> SUITE# BUSINESS PHONE <br /> SM ADDRESS - <br /> -I CYT Sr E zID C�S Zavf <br /> CITY r"\ _ ) \—n <br /> KI KEY2 <br /> BOARD OF$UPERVLSOR <br /> Cr LOCATION CODE <br /> Attention:or Care Of(optional) <br /> Mailing Address ifOIFFERENTfrorrr Facility Address ..S <br /> p PC1�l <br /> STATE ZIP <br /> Mailing Address City <br /> APN# IyA� ��7�QI COMMENT: <br /> SIC CODE 1 1 <br /> THIRD PARTY BILLING INFO; Completeif Billing.Party is different from Property Owner or Facility Operator identified above. <br /> /'' Attention:or Care Of (optional) <br /> BUSINAM <br /> ESS NE Eco <br /> .I'� \ le PHONE (qas) ass— L1E01 <br /> Mailing Address 1990 (41, c,l�t4q 1-j1Vd• �1'l� 0 7�a <br /> STATE C l� J <br /> ZIP 1 <br /> CM �) <br /> ED <br /> e r A «for fees and charges OWNER FACILITYIBUSINESS <br /> THIRD PARTY BILLING <br /> Rmj7 FEES, <br /> Ru I INC.INIIC - nr+rYT: L the undersigned.Applicant,certify that l am the Owner,(/permor,or AuOmriud Agent of this Business,anAll rerkvforlthsesiteatl also£certify that <br /> pecatnEs,E\'FORCY.11EY1'a/IARGE.$.and/or HOuw.l'C'ndfl(; S associated with This operation rill be billed pe meat the address identified above applicableth all the ' <br /> SAN <br /> UNTY <br /> amr,oragent af the pro pert), Ihereb ulhoriee the release a( <br /> all information prorided on this application is true and tions.U and that all regulated activities will be performed inaccordance ed let the abovtact ty/site adrt ss,I hcre Ordinance Codes ea or <br /> Standards and STATE an War FEDERAL Laws and Regulations. As the undersigned owner,oper <br /> information to SAN J0.4001N COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as looqpsit is avaiisbV angat the same time it is <br /> our and all results and environmental assessment <br /> providedlomeormyrepresen ' e. / PLEASE POINT SIGNATURE <br /> APPLICANT NAME G -'S'Qf <br /> �TITLE COpC'F- DRIVER'S HOTOCOPY REQUIRED)Ery I fIP-PF.� a <br /> Approved aY Date Accounting Once processing Completed BY • _ - - <br /> Date <br /> 29-02-002 April 25.200', <br />