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a <br /> San Jlaquln County Environmental Health Depqrtment <br /> GREENFORM <br /> DATA a ! MASTER FILE RECORD INFORMATION` - SITE MMISATIO&LOP <br /> M AAREAS tit 09 4aEO}bY orrttEtl.Iatl jI; UNIT IV <br /> 94 <br /> OWNIMRL,EiCoMPLEW THE FOUOWNoPROPERTY OWN ERIMPORMano ; rFOWNER CtfRRElVT1YdYF7LEttrntENo� <br /> PRMMOwwtNAME CAOL— I IVA IJ,P-4A op) , 0`3) OOD <br /> FYstM! Last PHOME NUMBER <br /> BusimEss NAhm E-mi.AoDRES3 <br /> tj I et r; �LGrJ0. • <br /> Owner Homs Address <br /> City STATE ZJ <br /> S <br /> owner MluUnp AddrwEs <br /> MtdtbM Address CRy •7 State 4 <br /> COMMUTIort O DUAN PAMVt=P D Fm At mpy© OTMM O <br /> &=hbTfOATWN_EkWntolIhUWAL ASSEsiliUMT—VoUnffARY CLEANLP QUALrTY HW PIPEIJIIE 1 l7A ON LbP <br /> FAptm IDS INvsR ACCOtN+ID PR tl!RO A ��/yrs G✓ <br /> �s3 0a�o,f��.yMIK, <br /> --6�,:Ms . <br /> FACILITY FLE CoxPLEw7 FFOLLowwa BUSINESS I FACILITY/SITE INFoRMATlON: <br /> Is this a NEW Business LocArKm riot prevknud l regulated by tha EwRoNMENTAL HFALTH DEPARTMENT? Yt:s D No <br /> Is this an EXISTING Buslness LOCAnON but a NEWy TYPE cf regulated Business? YES © No <br /> BuslMEsalFACLIT/SITE NAME � �Z7� l�®�v)• r l�Ysc �C �. - <br /> S RE f BuslNEsa <br /> CRY '��J � STATE YIP � l <br /> BOARDOFBUPPmttI01111 tT111CT LWATM COW 3 KEY1 KE+t2 <br /> Melting Addee:s IYOIFFFREIvrbwn Fie <br /> /ld*W Attertticn:orCare Of/ons! <br /> Mafnnp A idressCity STATE zap <br /> GICOM. APN/ jocittimT: AA c �s <br /> THIRD PAitTr 1fiLLfNo INFO: COMp/et&K BIIIIng Party IS 4f#ferent from Props Owner orFacillity Operator ldeaYfledebove. <br /> OLMU xa NAME Altentlon:crCare Of (opLlonel} <br /> Zc-t r�i , ► j <br /> ,.I�/7L� t••1 <br /> Mailing Address 0 — 7 <br /> Cm -� 13TATE ZrP <br /> G <br /> AQMMXAMM <br /> for.fees a4d ahatyes OWNER fnaurY/Busmss ICIRD PAR G <br /> L the smderat ted Appu ant,arllfy that ism the Owner,Opower,or Audiarhed Agent ofd&Benno,and 1 uknmiadge tivat ati PmthaT Fees, <br /> Prnnarrm%FJ rmcmwwrCTf r16Ef and/or XotrAcrCl 4W=atspclUrd with this operatbd wi[i be billed to rat at the addrms ldenti8ed above as the A for this I*-I also army that all <br /> tnformaRon provided on this app9cadoo Is true and correct•,and that all regatated aedvttks will be performed In aetardanm with all applieahk SAN JoAQtum Cotmry Ordinance Codes And/or <br /> Staeduds and SSATE and/or ftDM"Laws aria Regutatlota. As the undersigned maer,operator,w agent of the properly located at the abm racpity/sitc addrto,I hereby suthorhe the rectae of <br /> say sad an fouls sad envirunntental uscuumat Information to SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It Is avall"sad at the same time it is <br /> provi4ed to me or my representative. <br /> APPLICANT NAME(PI,FASE Pm1R) SItINATURE �� r <br /> TITLE TAX <br /> t7 ID# <br /> � - <br /> Dat. ...thrp oma.thocaflrrp Omnytand By <br /> -SRE MtT1GATIONAroUNr PAID DATE OF PAYMENT PAYMEKr TYPE REcen rr A CHECK/ REcarmn BY .oqk p y:•';. <br /> FEE: <br />