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San J aquin County Environmental Health D9partment <br /> j - I S -C1 S <br /> DATE MASTER FILE RECORD INFORMATION NFR" GREEN FORM <br /> cue ocunu�Fnx,. OWNER ID# CASE# UNIT IV <br /> OWNER FILE <br /> COMPLETE THEFOLLOWINGPROPERTY OWNER.ItyFoRmA i7om <br /> CliwarzF OWNER CIRREAWYONFILEWITN EHD <br /> piteffmOWNERNAME ffl&-- 1 l Q(-t-1 n PHONE a09- foo -o iy <br /> MI Last <br /> BUSINESS NAME SDC SEC/T"ID# <br /> Owner Home Address 11 N • (�caVIS RO QG� DRIYEte's LICENSE# <br /> C" Lo A'% STATE (-A ZIP g S a y a <br /> Dwner Mailing Address <br /> Mailing Address City State Zip <br /> Tsae nes nmx�xosm <br /> CDROoMTION❑ INDMDUAL l PARTNERSHIP❑ FED AGENCY❑ OnreR❑ <br /> FACILITY FILE <br /> FAauTY ID# CRO55 REFID# ACwuNTID# IW# <br /> ComPLETETHEF <br /> Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ No E <br /> Is this an EIOSTING Business LOCATION but a NEW TYPE of regulated Business? YES ❑ No E <br /> BUSINESS/FACD3TT/SITENAME <br /> SITE ADDRESS 1 1 O N ^ v \e CD at) <br /> SURE# /� BUSmESSS Peelle <br /> CITY Lo d ; u STAT C(-\ Zips a <br /> BDARDOFSUM:RVLWRDLSWU LOCwnott CODE KEYI KEYI <br /> Mailing Address IfDIFFERENTBIm FadrityAddn Atbentiomor Care Of(Iphbna?) <br /> Mailing Address City STATE ZIP <br /> SIC CODE APN# COMMENT: <br /> THIRD PARTY BILLING INFO: COMP/eteif Billing Party is ditferentfro?n Property Owner or Facility Operator identified above. <br /> BUSINESS NAME Attention:orCare Of <br /> KC Gncj , nee( C� mport� ricmy Lee. <br /> Mailing Address S (aS Co4+-% r) Lane Sv',A-e A "1ONB 70(�7-` q-7 -/4 o4a-S <br /> CITY V Ql c Q v 1\\'Ci STATE CT\ � 1 S (✓ V <br /> for fees and tharges OWNER FACILITY/BUSINESS THIRD PARTY BILLING <br /> Rn.uvr. <br /> AN.Cnams uera Arsrxnws vnrasrvr: 1,the undersigned Applicant,certify that 1 am the Owner,Operatoq or Authorized Agentof this Business,and 1 acknowledge that all PemarFEES, <br /> PENALTIES,ENEORCEMENrL Wzazs and/or H01=rCjWGAS associated with this operation will be billed tome at the address identified above as the ACcnrmvAnnencs for thissite. 1 also certify that <br /> eU information provided on this application Is eve and correct;and that all regulated activities will be performed to accordance with all applicable SAN JOAQUM Couvry Ordinance Codes and/or <br /> Smuch rds 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 asseasmmt Information to SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time kis <br /> provided AN N Mrcpresenbfiva V <br /> APPLICANT NAME � (l1y E, � � PRINT SIGNATURE <br /> TITLE L1)v I r on M C,( Cd / \SS P S S G DRIVER'S LICENSE# a' <br /> fPHDTDCDPY REOUmED) <br /> Approved aY Gate ADnurNsq otrlee Pmtastell"Completed BY - Date <br /> 29-02-002 April25,2003 (��Q, Z 7-3 <br />