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I <br /> San Joaquin County Environmental Health Department <br /> DATEGREEN FORM <br /> 2 � '" n <br /> 3 MASTER FILE RECORD INFORMATION MFR <br /> OWNER II1# �o UNIT <br /> IV <br /> OWNER FILE <br /> OMPLETE THEFOLLOWIMG PROPERTY OWNERINFORMATION' GNECKIF OWNER CrrtrxeNTzraarFi►EwrT1t EHD <br /> PROPERTY OWNER NAME !f <br /> !j PHONE } <br /> t nit 17 <br /> zxi—93 fl6z� liJ <br /> BUSINESS NAME i 1 A r �Ct fl [1N j' SOC SEC/TAX ID# <br /> GVC"i O" Wn p�� T 7b fC <br /> Owner Home Address �� C <br /> W �y t -� P�i� !1 DRIVER'S LICENSE# <br /> C4r C ] CJ !# <br /> Owner Mailing Address T <br /> i} <br /> Mailing Address City I State Zip <br /> TYoc nc rlwxcocura <br /> CORPORATION❑ INDMDUAL❑ PARTNERSHIP❑ !� FEDAGENCY❑ OT'HE <br /> FACILITY FILE I. <br /> I"AOLIFI, �R055.IZEFI,II t. AExOUxr;D { XNY�!' <br /> Is this a NEW Business Lom-nom not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES No ❑ <br /> Is this an EXISTING Business LocATION but a NEW TYPE of regulated Business? 11. YES ❑ No ❑ <br /> BUSINESS/FACILITY/SITE NAMji <br /> E <br /> . SrU�VJ eY <br /> SITEAD[M [.qVH�dd V �iiI <br /> E5s 2-21- 5117E# BUSINESS PHONE <br /> f/f <br /> ' <br /> } <br /> cnY J�f�CK I� STATE <br /> CA <br /> ZIP n 5L o Z <br /> :7 mor <br /> :BOARf}�FSUPERVJSOklD 7[YICT'>... .:--;:. .... -:tbCATION: ODE:::::9: <br /> Mailing Address ifDIFFERENTfmmFacllityAddress I Attention:or CareOf(optional) <br /> �1 ti <br /> Mailing Address City STATE Z.IP <br /> ..,SIC CODE.<:. <br /> ;: <br /> :,..,. . <br /> i <br /> i <br /> THIRD p'AWM BILLING INFO: Complete if Billing Party is different from Property Owner or Facility Operator identified above. <br /> BUSINESS NAMEJATC ��� Attention:orCare Of (Opdfonao <br /> go 5ex <br /> Mailing Address p p j�yc �J�j� s✓7rP i PHONE <br /> CnY �1 STATE ZIP! r S]S f <br /> �a�cfTv I� <br /> k <br /> ArY` tA=ApDgc c � <br /> for fees and charges OWNER FACILITYIBUSINESS THIRD PARTY BILLING � <br /> Rn j.'W dvn(`n.,vl, 1,the undersigned Applicant,certify that i am the Owner,Operator,or Authorized Agent of this Business,and 1 acknowledge that 911 PERNITFEE <br /> PF ALTIsf,ENFORCEMENT CHARGES and/or HOURLY CHARGES associated with this aperation will he billed to me at the address identified above as the AcmtjyTAnDRrv3S for this site. 1 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 COUNTv 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 facilitylsite address,I hereby authorize the release of <br /> any and aU results and environmental assessment Information to SAN JOAQUIN COUNTY ENVIRONMENTAL HEAtTK DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my representative. PLEASE PRINT N <br /> I! '��l'r <br /> APPLICANT NAME a KV�fd1f*�— SIGATURr/��/%� <br /> TITLE PH�COPY REQUIRED) <br /> Approved By Date Amounting 0frice Processing Completed By �� Date ��13e�03 <br /> innxnoi� i uu� <br /> IG M M� A...:1 oc gnnz ij <br />