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San Auin County Environmental Health eartment <br /> DATE MASTER FILE RECORDINFORMATION "MFR" GREEN FORM <br /> 886END USE ON WNER <br /> OID# CasE# UNIT IV <br /> OWNER FILE <br /> COMPLETE THEFOLLOWING PROPERTY OWNER/NFORMA nom CHECK/F OWNER CURRENTLY ON FILE WrH EHO El <br /> PROPERTY OWNER NAME PHONE <br /> First MI Lest <br /> BUMNESSNAME ' t� �iArh {� r.l_ usSOCSEC/TAafD# <br /> Owner Home Address 1 �0. 1 GV--, � <br /> {{ CttVORNER'6LICENSE# <br /> city 5U4-� -r C ree 1-_ STATE e ZIP 9 5F_Si C <br /> Owner Mailing Addreae ( SO tZ a-1 L AN tom- R 1 VL-� lff!!U+] <br /> Mailing Address City 5U`rCLZ C Y?-c E{L State CA ZIP g5(n$ <br /> CORPORATION❑ INDIVIDUAL[] PARTNERSHIP El FED AGENCY❑ OTHER❑ <br /> FACILITY FILE <br /> FACILRY ID# CROSS REF ID# ACCOUNT ID If INV# <br /> COMPLETETNEFOLLOWiNG BUSINESS!FACILITY/SITE INFORMATION: <br /> Is this a NEW Business LOCATION not previctisly regulated by the ENVIRONMENTAL HEALTH DEPT.? YES ❑ NO 2Y <br /> IS this an EXISTING Business LOCATION beta NEW TYPE Of regulated Business? Yes ❑ No ❑ <br /> BUSINESS/FACILm/SITE NAME {'ORMUZ UNO(AL.. bVC.IC f'a.rarT �. O'j <br /> Sm ADDaEfi3 23o3 6. I ✓rKGG SURE# SUSINESSPHONE <br /> DRY T\'G <br /> kA C�i STATEcic) ZIP �Z Sa DLf <br /> BOARDOFSUFERVISOROISTRICT LOCATION CODE NEY1 1(Ey2 yv�V <br /> Mafling Address HD/FFERENTfrom Faci/l/yAddreas Attention:Or Care Of fopbonal/ <br /> V) <br /> Melling Address City <br /> STATE ZIP I <br /> SIC CooE APN# COMMENT; <br /> THIRD PARTY BILLING INFO: Complete dBilling Party is different from Property Owner orFacility Operator identified above. <br /> BususEss NAME Attention:or Care Of fopt/onal) <br /> cf�feL Co^5vl�l^ th\#alzl��, f3g1�, <br /> MaIfl gAddreas <br /> CITY Q _f1CL'o (] <br /> �` 0. �4\ _tCJ� '1 <br /> �IR TlJ STATE(2yN ZIP <br /> d�-4weew for fees and charges r"T OWNER FAciuTY/BUSINESS rTHIRD PARTY BILLING <br /> BILLING AND COMPLIANCE ACKNOWLEDGMENT: 1,the undersigned Applicant,cerdfy that 1 am the Owner,O permor,or Authorhed Agest of this Business,and I acknowledge that all PERRDTFEn <br /> P£HALREs,Emfvxc d/£NTCHARGEY and/or HHHRLYCHARGEf associated with this operation will be billed to me at the address identified stays as the ALrntlNTA/utReAP(arlhis site (alsoartify Nat <br /> all Information provided on this application b true end enrrca;and that a6 regulated acdNtim will be performed in accordance with all applicable SAN JOAQUIN COu. Ordinance Coda and/or <br /> SUnd.rdsa.d STAT[an(l/or FEa LLaw9..d Regvtadons. As the undeaigned niner,.perat.,oragentofthe property located at the abovefaclSly/sheaddress,l hereby authorize the release of <br /> any and all results and envirannemai asaosmmt Information to SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is.,.liable and at them.,time It is <br /> provided to me or my representative. <br /> APPUCANTNAME (Y�Wf21� �, '�� PLEASE PRINT SIGNATURE Iekfz j:� <br /> TITLEDRIVER'S LICENSE# <br /> SeNt 02 C LO(ACitS r <br /> _(PHOTOCOPY REOUIREOI <br /> APProved BY Data APCounUng DRICB Procauing ComplatW BY Data <br /> 29-02 10/12/07 MASTER FILE RECORD- <br /> GREEN <br />