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San Joay,.lin County Environmental Health Department <br /> DATE ���Cv�L5 MASTER FILE RECORD INFORMATION "MFR" GREEN FORM <br /> SHADED AREAS FOR EHO USE ONLY OWNER ID/ CASE UNIT IV <br /> OWNER FILE <br /> COAIPLETETNEFOLLOw/NGPROPERTY OWNER/NFOR111b4T/ m CHECKiF OWNER CURRENTLYONFTLEwnN END <br /> PROPERTY OWNER NAME PHONE <br /> First MI Last <br /> BUSINESS NAME �^ Soc SEC I TAx ID N <br /> Sss-Tf" <br /> Owner Home Address Z9 A 2 s DRNER'S LICENSE# <br /> I J <br /> City STATE L� zip <br /> v <br /> Owner MaNing Address <br /> Mailing Address City S Ata rr� state 'K Zip -�$Zy <br /> CORPORATION, INDIVIDUAL❑ PARTNERSHIP❑ FED AGENCY❑ OTHER❑ <br /> FACILITY FILE <br /> LF�UT:Y'�D <br /> # CRossREFID# AccouNT ID# INV1 <br /> CoMPLErETrrEFouowrNG BUSINESS I FACILITY I SITE/NFoRw WN. <br /> Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPT.? YES ❑ No.,q <br /> Is this an EXISTING Business LOCATION but a NEW TYPE Of regulated Business? YES ❑ No <br /> BUSINESSIFACILITYfSITE NAME <br /> SITE ADDRESS -t-� SUITE* BUSINESS PHONE <br /> CITY f STATE(—A LP 17, <br /> BOARD OF SUPERVISOR DISTRICT LOCATION CODE f KEY1 KEY2 <br /> Mailing Address KOIFFEREA?fiam Fw#AtieAattihess Attention:or Care Of(opBarel) <br /> Mailing Address City STATE zip <br /> SIC CODE <br /> =APNP CoMMENr. <br /> THIRD PARTY BILLING INFO: Complete ifBilling Party is different from Property Owner or Facility Operator identified above. <br /> BUSINESS NAME -1 Attention:orCare Of(tpgonal) <br /> Sc-t <br /> ^ 2 ..:) S41 fin, <br /> Mailing Address ��15 Sw n PHGNE <br /> 1-W e,, �3 .4_+c) x- <br /> CITY1 STATE,,,_ ZIP <br /> "I4ec"j <br /> AccoyArrAclamm for fees and charges OWNER FACILITY/BUSINESS THIRD PARTY BILLING <br /> BILLING AND COMPLIANCE ACKNOWLEDGMEN'I': 1,the undersigned Applicant,certify that I am the Owner,Operator,or.t utdorized:[gent of this Business,and I acknowledge that all PER.WT FEtS, <br /> PL'N.aLTiLS,E.vF0RCEVE%TCH4RcLS and/or 1101 RLtCH.IRGE.S associated with this operation will be billed to me at the address identified above as the Accot:vTADDRL'sS for this site. 1 also certify that <br /> all information provided on this application is true and correct:and that all regulated activities will he performed in accordance with all applicable SAN JOAQUIN COI NTI Ordinance Codes and/or <br /> Standards and ST'S rE and/or FEDERAL Laws and Regulations. As the undersigned owner,operator,or agent of the property located at the above facility/site address,1 hereby authorize the release of <br /> any and all results and environmental assessment information to SAV JOAQUIN COENTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my representative. <br /> APPLICANT NAME nn PLEASE PRINT SIGNATURE <br /> TITLE 11 11 DRIVER'S LICENSE N <br /> �2-O�Vii.i n-�O:�C{wGG�-L'Ls t 5� (PHOTOCOPY REQUIREDI <br /> Approved By Date Accoun"Office Processing Completed By Date <br /> 29-0' 10'12.07 MASTER FILE RECORD-GREEN <br />