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riJ110/LCJCJL 10. :JCJ 4u7400343S rlr In rLUurt r P*m= u 1 <br /> DATE GREEN FORM <br /> MASTER FILE RECOR6 INFORMATION `'MFR" <br /> UNDT 9V- <br /> OWNER PILE <br /> COMPLE7E7HEIg7�1dWINGP dPERTY OWNSIWORMAI7ON, od"'"F OWNER CtQMdrrzrt VVMEWZMEHD <br /> Faomm owm3t - <br /> FIAW go e) OPT, <br /> 11 <br /> (0,gjq ).(y3,3 <br /> A <br /> B[tsztUSS NAME <br /> Sot St c/TAX ID* <br /> Owtter Hartne Addt>✓s t�\Q , molt's LzcffwE*city 21P <br /> C <br /> Mailing Address City Stake Zip <br /> nammw❑ rNr,,.lrev w vaa r..arrea,v❑ tea►arxwry❑ t]rrsa❑ <br /> V FILE <br /> Is IN$a Kr*SUSitWO LOCATM nit Pmftusly mvutalRd by the RMW1 41NIIAL Heum DEPAUMENi7 YEs ❑ NO <br /> 1s ft an DtISsmm M170fN but a HeirTYPE of regulated Business? YES ❑ No <br /> 8t15nttE55/F tNAME N 5VT-P,L T� K1AJD6jE Po 9,t1.2AAJ <br /> slreAnpREss /I�4M D ��. v AiC 1 o ti Btds Pltmte <br /> OUT �Q $fAte, ZIP <br /> cif' <br /> A <br /> Mallog Address ff,0R7EREIYI''ftmFa-Wfy Attantkin:or C;mrL>Of(, . <br /> R <br /> 3 1000 <br /> Marling Addrem City y <br /> a <br /> THIRD PARTY BILLING IINFo; Compkte if Billing Party is dffera7tfxm Property Owner or Facility Operator k ndfieq'above. <br /> Bttsatess NAt , Attention:arCare of (apamwo <br /> Mailing Address C ' PHo t 0 _)( S 1 -,2 <br /> CrTM V SPATE Svc/1 1 <br /> fbr fees and Chaff OWNER FAC:LMYMUSINESS 1110 PARTY BILLING <br /> 7R <br /> Irl LING AND f A&M ANfT.APKNm_:,,L . .:..• I,d*nadCRkpcd Applicant?certify OM I am Me OpmR ,Off&Orr Qr At dharj Yl Ag&W a(tens Bvmimeas�Znd I ackfic Wleftc ttlat all pERAQlf Fm:sS <br /> %NALnes.E1v 0RCAv6NrCAA GW and/or HOMY CRAAr.Es amodated with this uperadoe will be bMW In meat the mddrss IdenttW above m the Amur=dnuancm for this site. f aW pertify that all <br /> albrmallm provided on this application is true mod comet;and that all regulated activities will be performed in cacordmtee with all mpplkable SAN JOAQwn Com-ff Ordinance Codes and/or <br /> Mmol nts and STATE and/or FsDmAL Lam and Regulatiom. Am the undersiped owner.amrator,or agent of the property located at the above,fadtlty/•ite address,r hereby anthrrimme the release of <br /> my cad all restuts and envlrottmenbl mpessment information to SAN JOAQUIN COUNTY ENVIRONMENENTAL HEALTr DIkRTMEINrT as soon m It is available and at the same fine it is <br /> rovidcd tome or ray rresenhWe. 1 <br /> ATNAME s><cNATU <br /> Pp1DGN ' <br /> TITLE S/' /lyJy/ -/S'�'G�t�` /`t! Drasw 1 <br />