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San Joouin County Environmental Health Department <br /> GREEN FORM <br /> DATE MASTER FILE RECORD INFORMATION I`MFRfr 1 ' <br /> cuencn eocec cno FHniicr n,,, OWNER ID# �Tl L031 2-2-- CASE# UNIT IV <br /> (r OWNER FILE <br /> COMPLETE 7NE FOLLOWING PROPERTY OWNER INFORMATION: Cf+E%ycfF OWNER CURRENarcW zEwrrn EHD <br /> PROPERTYOWNERNAME PHONE <br /> First MI Last <br /> BUSDIESS NAME rl f {t <br /> Owner Home Addrea U <br /> city STATE ZIP <br /> Owner Mailing Address .-r-+ � IOS� ,0. Ch- ! 8✓1 `�- / <br /> Mailing Address City 1—, _ S*2 `bi -D � Stale f Zip r-7+�CLw <br /> CORPORATIONX INDMDUAL❑ PARTNERSHIP❑ FED AGENCY❑ OTHER❑ <br /> FACILITY FILE .� s-/ <br /> FACILITY ID# ' -� CROSS REF ID.A ACCOUNT ID# �T 1l INV# <br /> CompLm O LOWI G NFOR TI N' O V C <br /> Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ Noz <br /> IS this an OUSTING Business LOCATION but a NEW TYPE Of regulated BUslnws7 YES ❑ Noo <br /> BOsmEss/FAtnnY/SITENAME ..111///r L 1IIZps.0 1 � . <br /> SMADDREss % ^�'�1tO /'+. CM Ov 1... sum# BUSINESSPPHONE <br /> CIiv —f _J Its--1 \✓ 1 STAT 1 ZIP9J ZI J <br /> BOARD OF SUPERVLSOR DISTRICT LOCATIUN CODE KEY1 KEY2 <br /> Mailing rens ifD RENTTFarAddress Attention:or Care Of(optional) <br /> Mailing Address City T - 5� /•/�-U STATEZia ���i LA <br /> SIC CODE J f� APN# l Q I'j'(O C)L f COMMENT: G�it— <br /> THIRD PARTY BILLING INFO; Comp/eteif Billing Party is different from Property Owner or Facility Operator iden&?Zedabove. <br /> BUSINESS NAME '�"� Attention:or Care Of (optional) <br /> J e,PyzL 'LG`7 G--)VISS1�4 lw <br /> Mailing Address I JOO C'L r7C• SK I IZ PHONE (� ,r3S1 <br /> Criv S STATE/L 'L U ZIP <br /> for fees and charges OWNER FACILITY/BUSINESS /V THIRD PARTY BILLING <br /> HIT I TNG AND COMA tANrT ACKNnwt snrmexr; I,the undersigned Applican4 certify that I am the Owner,Operator,orAmhorked Agent of this Business,and-1.dmowledge that all PEANUT FEES, <br /> PENALTIES,ENFORCEMENFCHARGM and/or ROORLYCRARG£S associated with this operation will be billed to me at the address identified above as the ArY'n ADDRETC for this site. 1 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 Coda and/or <br /> Standards and STATE and)ar FEDERAL Laws and Regulations. As the undersigned owner,operator,or agent of the property located at the above facility/sire address,I hereby authorize the release of <br /> any and all results and environmental assessment information to SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPART A as soon as t n 'le a and at the sam�itt <br /> provided to me or my representative <br /> APPLICANT NAME �� oq_ SIGNATURE �� 1{8 <br /> TITLS LI E DRIVERNSE# 't,, tjStj <br /> 411 G'�.UIG q lI (P1gIOCOPY RE IReD) J/✓lJ <br /> Approved By Data 11 Accounting OTice Processing Completed BY Date C� <br /> 29-02-002 Apri125,2003 <br /> CONFIDEN IA <br />