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San Joaquin County Environmental Health Department <br /> DATE <br /> * GREEN FORM <br /> 6 MASTER FILE RECORD INFORMATION "MFR" <br /> UNIT IV <br /> OWNER FILE <br /> COMPLETE TNEFOLLOWING PROPERTY OWNER INFORMATION; CNELYIF OWNER CUa#rnnYONFnc WM END El <br /> PaQPFntt OWNER NAMEiy, vc/ 7!i�_ P E � <br /> V�� First MI VV 1Y( Lag V VV L <br /> BUSTNESSNANE /'i.• SOCSEc/TA%ID# 3!// <br /> Owner Home Address /' Dw FVS LIrFrvSE# <br /> City to ;r ZIP <br /> Owner Mailing Addrgs <br /> Mailing Address City <br /> rstat <br /> TvncnenwNnnaan <br /> CORPORATION❑ INDIVIWAL Pu ER El Fm AGE E] OIHEB❑ <br /> FACILITY FILE <br /> Famltt;D# CROSS REF ID#. ACCOUNT ID# 'INV# <br /> COMELVE 7HF FOLLOMNC BUSIN ESS I FACILITY SITE ZMEP—Rm71 N' <br /> Is this a New Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ No <br /> Is this an EMSrING Business LOCATION but a NEW TYPE of regulated Business? YES ❑ N <br /> BUMESS/FamI1Y/SnENAME J <br /> SITE ADDRESS / ` SUnE# BUSINESS Pf E <br /> S <br /> Cm' YGh.G�- U STATE ffi 5 52 3 <br /> Mailing Address ifDJFFERENTfrorn FadlityAddress a/) <br /> Mailing Address City SEF G 9TaR08 Z8 <br /> EM/IROINIV!ENT HEALTH <br /> THIRD PARTY BILLING INFO; Complete%f Billing Party is different from Property Owner or Facility Operator identified above, <br /> BQS1N65 NAME Attention: wCare Of (oPfiOnaQ <br /> ASG oc > 7✓ <br /> Mailing Address <br /> ,ac do sof>c aai PIgNE 5-7 zzz./ <br /> TMSTATEC A ZIP91S3s/ <br /> !No'��s7o <br /> Accau gcAo o&&w for fees and charges OWNER FACILITY/BUSINESS THIRD PARTY BILLING <br /> BILLING AND COMPI roNCE AMNOWI rnNNIEW: I,the undersigned Applicant,certify that I am the Owner,Operator,or Authorized Agent of this Business,and I acknowledge that all PEMirr FEES, <br /> P£N Ua,ENEOACEN£NlCHAR and/or ROUELYCHARGES associated with this operation will be billed tome at the address identified above as the Ar UWADDRESS for this site. I also certify,hal <br /> all information provided on this application is true and correct;and that all regulated activities will be performed in accordance with all applicable SANJOAQMN COUNTY Ordinance Codes and/or <br /> Standards and STATE and/or FEDERAL Laws and Regulations. As the undersigned owner,operator,or agent ofthe property located at the above facility/site address,l hereby authorize the release of <br /> any and all results and environmental assessment informatio to SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available an7tt same ties it is <br /> yrovided to me or my re esenW 'e. J� r/ <br /> APPLICANT NAME PRBfT SIGNATURE <br /> TIRE <br /> DRIVER'S LICENSE# <br /> (rH0tQ0)VYREQUDIEDI <br /> Apposed aY DaleAemuntmgi Office Processing Care~By Dale <br /> 29-02-002 April 25,2003 <br />