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San Join County Environmental Health apartment <br /> GREEN FORM <br /> DATE //�)Z�°} MASTER FILE RECORD INFORMATION "MFR" <br /> cWArFn ApPag FroFHnecenu,v OWNER ID# 13I2– /— CASE# UNIT IV <br /> OWNER FILE <br /> COMPLETETHEFOLLOWING PROPERTY OWNER INFORMATION; 0,rcrrF OWNER CURREVrZYOMFIEE wm/EHD <br /> PROPERTY OWNER NAME STEVE GIANNECCH/N1 PHONE Zo9- 93/—.5'�SZ <br /> First MI Last <br /> Bustrass NAME G/ANNECc H1.v/ corer PAlvy Soc SEc/Tm ID# <br /> Owner Home Address DRIVER'S LIc iNse# <br /> city STALE ZW <br /> Owner Mailing Address 3Es/ At. TAC/[. 7 /Ve RD. <br /> Mailing Address City -C 70 C/47D/V State CA ZIP 9S2/S <br /> Tvec ncnw <br /> CORPORATION® INDDRDUAL❑ PARTNERSHIP❑ FED AGENCY❑ ODIER❑ <br /> FACILITY FILE <br /> FAQLITY ID# 1 bZ�g CROSS REF ID# AccoUNT ID# Zg3b INV# <br /> COMPLETE THEFOLLOHqNG BUSINESS If FACTUTY It SITE INFoRmA77om, <br /> Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ No ❑ <br /> Is this an EXISTING Business LOCATION but a NEW TYPE of regulated Business? YES ❑ No ❑ <br /> BUSINESS/FAt /SITE NAME B)Z17-t FE977L111V G. <br /> Srnz ADDRESS ?�� S. JACK TINE RD. Sum# BUSINESS PHONE <br /> 20 9-Y 6/-656 S <br /> Cm S7DCJL7vN STATE CA ZIP 9S2/s' <br /> BOARD OF SUPERVISOR DISMCr LOCATION CODE KEYS KEYZ <br /> Mailing Address ifDIFFERENTtvm Fad/ityAddress Attention:or Care Of(optional) <br /> 3265 W. F1 cARDE.v DAVID SA/7--;-L <br /> Mailing Address City STATE Zen <br /> FRESNO C,) 93 5t/1 <br /> SIC CODE APN# COMMENT: <br /> THIRD PARTY BILLING INFO: Complete if Billing Party is differentfiom Property Owner orFacility Operator identified above. <br /> BUSINESS NAME Attention:orCam Of (optional) <br /> + r v T6TLRAco.v coNtu LTA.vrs lAic. 7 Fs K/EP�lq* <br /> Mailing Address PHONE <br /> ;)'Vol 6AL/LEE RASur7F Ysa 9/c - �8 y— 2283 <br /> CITY STATE ZIP <br /> /ZOSEy/LLE �A 9s`a8 <br /> for fees and charges OWNER FACILITY/BUSINESS C THIRD PARTY BILLING <br /> I,the undersigned Applicant,certify that I am the owner,Operator,or Authorized Agent of this Business,and I acknowledge that all PE IFFEEs, <br /> PEArlcs,ENFOWc AfEATCrue and/or ROUBLTCHAEGEe associated with this operation will be billed tome at the address identified above as the AcrO=AODR 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 COUNTY Ordinance Codes mud/or <br /> Standards and STATE and/or FEDERAL Laws and Regulations. As the undersigned owner,operator,or agent of the property located at the above facility/site address,I hereby authorize the release of <br /> any and all results and environmental assessment information to SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the some time it is <br /> provided to me or my representative. <br /> APPLICANT NAME SAMES .K/E7LN�N'(7E)ZRrf C.N� SIGNATURE \. <br /> p <br /> TITLE DRIVER'S LICENSE# <br /> ENVIX-MIAENT-hL DET zTMENT MAWACE7L (PHOTOIXIPYREOUIREDI AES6z/-:;2 <br /> Approved By �. /�— Date �� j C i Accounting Office Processing Completed By a <br /> rr , <br /> 90-09-009 Ann)75 1001 � <br />