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San Joaquin County )lic Health Services Environmen.. lealth Division <br /> GREEN FORM <br /> DATE MASTER FILE RECORD INFORMATION "MFR" 1 <br /> Sa - <br /> "l. j J OWNER ID# CASE# UNIT IV <br /> OWNER FILE q <br /> CHEIXIF OWNER CY/RREMLYON vtte wmrEHD <br /> COMPLETE THEFOLLOWTNGPROPERTY OWNER INFORMATION; <br /> PROPERTY OWNE0. \ ^ I� n�. PHONE <br /> NAME S1'�',` \(�, • QV 61 R-0 0 <br /> First MI fast <br /> BUSINESS NAME SOC SEC/TAX 1D# <br /> Owner Home Address d ryc de: Dan;ER's LICENSE At <br /> D e ' dZ5e D <br /> City STATE ZIP <br /> Ownn MailitI Ask— <br /> Mailing Address City bLV ro v State Zi <br /> roc nc nwxcacsno <br /> fnvenventw Tnnnrtnne, DevTucocuw❑ Fen Ale.,❑ OTucv❑ <br /> Fernm Tn as ranccevv TnA arrm,urIDB INV# <br /> ' <br /> Is Nis a N.Business Lof Tfcm not previously regulated by the ENVIRONMENTAL HEALTH DIVISION 7 YES ❑ NO <br /> Is this an EXISTING Business LOCATION but a Nm TYPE of regulated Business? YES ❑ No ❑ <br /> BUSINESS/FACILITY/SITE NAME <br /> 1lERCtN Se=T:_v� P StAki-A ZLI8- <br /> CV <br /> Sm ADDaFSs SUITE# BUSINESS PHONE <br /> 19(n0 V1EST 1\" S�cl � <br /> zip <br /> t7 r <br /> TRp.�y $'c AL 9s3�co <br /> BOAROOF$UPERVISORDisrmCT I I LOcATTONCODEI I� I KEv1 I I K"2I II <br /> Mailing Address ifDIFFERENTinom Facifi Address (�Idti('Oa P",,s Go:'rcy Attention:or Care Of(optional) <br /> i II V <br /> Mailing Address City STATE P 3 <br /> k QIseL6 <br /> $IC CAD.. 11 "N# COMMERT: <br /> THIRD PARTY BILLING INFO: Complete if Billing Party is different from Property Owner or Facility Operator identified above. <br /> BUSINESS NAME ll? /n� / Attention:orCare Of (optional) <br /> Mailing Address rc ' ' ! PHONE 00 <br /> Qn RoadOV <br /> CITYAC—�S O STATE � tg b f CJ V <br /> Ac4QLmT DQ9ESC for fees and charges OWNER FACILITYIBUSINESS THIRD PARTY BILLING <br /> q ! sm tavry Ar¢anws vncntcvr L the undersigned Applicant,certify that I am the Owner,Operator,or Authorized Agent of this Business,and I acknowledge that all PE.CNIT FEET, <br /> PENALTIES EN£OACEMENT CHARGES and/or llouaIY CHAAGFS associated with this operation will be billed to me at the address Identified above as the Arrnnrrr Annaysv for this site. I also certify that all <br /> Information provided on this application is true and correct; and that all regulated activities will be performed in accordance with all applicable SAN JOAQUIN CoI Ordinance Codes and/or <br /> Standards and STATE and/or FEDE1 Laws and Regulations. As the undersigned owner,operator,or agent of the property located at the above facility/site address,1 hereby authorin the release of <br /> any and all results and environmental assessment information to SAN JOAQU IN COUNTY ENVIRON NI ENTAL HEALTH DIVISION as soon as it is available and at the same time it is provided to <br /> me or my representative. <br /> PLEASE Paxrn <br /> APPLICANT NAME YIl LL �-� SIGNATURE <br /> 7711 r10T[I'✓t ' L, <br /> DRIVER'$LICSE# <br /> TITITLEOrF 011e G Ld; �'4 e(l�LIQt (PHorotow aEENoulaEDl O <br /> Approved By:;. Date Aaounting Office Processing Completed BY �.Date 7= <br />