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San Joaquin County Environmental Health Department <br /> GREEN FORM <br /> DATE y MASTER FILE RECORD INFORMATION "MFR" <br /> cHenm ARFAC Frig clan ucF(TNI v OWNER ID# CASE# UNIT IV <br /> i <br /> OWNER FILE <br /> COMPLETFTHEFOLLOWING PROPERTY OWNER INFORMATION; CHECKIF OWNER CuRR{E�NTLroNFTLEwrrH EHD <br /> PROPERTY OWNER NAME PHONE Z I V _3 1 s— zoo 0 <br /> First MI Last <br /> BUSINESS NAME ,Ialtr O SOC SEC/TAx ID#N - •,o} p_ o art' - <br /> v Er1�r [or dCa iOh tJ Re <br /> Owner Home Address 011L V011ltro way DRIVER'S DRIVER' LICENSE# frb'trfr OWAtr QA�yj <br /> C N A — <br /> city Sa^ I//�\��In 1 O STATE T Y zip �� _ /6 16 <br /> Owner Mailing Address Pv g ox 6 9 6 O D O /� <br /> Mailing Address City saw State T-X Ztp 4 92-61 - 000 <br /> TVDF AF nWNFRCHTP <br /> CORPORATION INDIVIDUAL❑ PARTNERSHIP❑ FED AGENCY❑ OTHER❑ <br /> FACILITY FILE <br /> FACILITY ID# CRoss REF ID# ACCOUNT ID# INV# <br /> OMPLETE THE F LLOWING BUSINESS I FACILITY SITE INFORMA7TOly.' <br /> Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ No Cil <br /> Is this an EXISTING Business LOCATION but a NEW TYPE of regulated CBusiness? YES ❑ No LJ <br /> BUSINESS/FAmrrY/SIrE NAME vole O EA!:!�y <br /> 1 T- <br /> SITE ADDRESS 2 C U C A/ SUITE# BUSINESS PHONE <br /> JJ J IVav l�rlvl. 570- $ - D X/10 <br /> CITY S�vck+oh STATE CA ZIP �SZ03 <br /> BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEYZ �; KEY2 <br /> I <br /> Mailing Address tfDIFFERF�NT from Faci/i�yAddress Attention:or Care Of(optional) <br /> SOA Fab/o AVe,1 1— 'Rl� 8r0.t�oliS� R��roAe( µSE Mq�. <br /> Mailing Address City �j�{-f' 7 <br /> (,f 1 STATE CA ZIP 9q 5--?5-- <br /> LEIC <br /> CODE � APN# COMMENT: `{ <br /> DARTY BILLING INFO: Complete if Billing Party is different from Property Owner or Facility Operator identified above. <br /> JSS NAME AtteRf -- <br /> nF "national _ <br /> Mailing Add"7 Z/17 LALI(- Q� I-1 PHO <br /> Cm l Cil�- STATE/ �� ZIP <br /> l�.f� ty <br /> ercawgAaagEss for fees and charges OWNER FACILITY/BUSINESS THIRD PARTY BILLING <br /> Bn t ING AND('On[PI.1AN('F Afjj-%j 'LU)(;MT NI: 1,the undersigned Applicant.certify that 1 am the(honer,Operator,or Authorized agent of this Business.and I acknowledge that all PERnf1'7'FEEs, <br /> PEAALTIES,ENFORCEAffiA7 CHAR6.E.V and/or HOURLI CHARGES associated with this operation will be billed to me at the address identified above as the ACCOU%7 ADnRFt'.0 for this site. I also certify that <br /> all information provided on this application is true and correct:and that all regulated activities will be performed in accordance with all applicable SAN JOAQUIN COh'NT1 Ordinance Codes and/or <br /> Standards and STATE and/or FEDERAL Laws and ReYulations. As the undersigned owner,operator,or agent of the properq located at the above facility/site address,1 hereby authorize the release of <br /> any and all result%and environmental assessment information to SAN JOAQUIN COUNTY ENVIRONNIEN'TAL HEALTH DEPARTMENT as <br /> soon as it is available and at the same time it is <br /> provided to me or my representative <br /> !� PLEASE PRINT SIGNATURE <br /> APPLICANT NAME <br /> II. U0.rk, <br /> MILE /l�/( / L DRIVER'S LICENSE# b C 5-4 00q I <br /> Task Hagg C 6TAFr Gtp Q 15 r (PHOTOCOPY REQUIRED) <br /> Approved By ([_ DateAccounting Office Processing Completed By Date <br /> 29-02-007 April2�.200: <br />