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-2. 7 � <br /> 0 <br /> San Joaquin County Environmental Health DepartmentLam.cL;511 <br /> �ED <br /> DATE / - GREEN FORM <br /> ( I MASTER FILE RECORD INFORMATION "MFR" jLiI J 0 2007 <br /> SHlnFn eRFe<FnR FHn ncF nNi r OWNER ID# CASE# <br /> I Fri{ I Fj <br /> OWNER FILE 'b L.9 /!CES <br /> COMPLETE THEFOLLOWINGPROPERTY OWNER INFORMATION; CHECKIF OWNER Cuartenrrcronvr[ewnH E^HDEl <br /> PROPERTY OWNER NAME PHONE e _ <br /> First M1 Last !� <br /> BUSINESS NAME Soc SEC/TAx ID# <br /> Owner Home Address � '�j ( / `(1 ; Q DRIVER'S LICENSE# <br /> CICy STATE <br /> Owner Mailing Address LL <br /> Mailing Address City zip <br /> TVRF OF DWNFRCHID <br /> CORPORATION© INDIVIDUAL❑ PARTNERSHIP❑ FED AGENCY❑ OTHER❑ <br /> FACILITY FILE <br /> FACILITY ID# CROSS REF ID# ACCOUNT ID# INV# <br /> COMPLETE THE FOLLOWING BUSINESS I FACILITY I SITE INFORMA770N.' <br /> Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ No <br /> Is this an E)aSTINO Business LOCATION but a NEW TYPE of regulated Business? pppp YES U No ❑ <br /> BUSINESS/FACILITY/SITE NAME T y. <br /> 0AJ 4— <br /> $ITE ADDRESS 1 SUITE# BUSINESS PHONE <br /> ar c 7 STATE A zIP C 3 <br /> BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEY1 KEYz <br /> Mailing Address ifDIFFEREAThom Fat-//ityAddress Atbention:or Care Of(optional) <br /> Mailing Address City STATE ZIP <br /> SIC CODE <br /> AP # COMMENT: <br /> --:71 <br /> THIRD PARTY BILLING INFO: Complete if Billing Party is differentfrom Property Owner or Facility Operator identified above. <br /> BUSINESS NAME Ammon:orcare Of Ptlona/) <br /> Mailing Address 5�D A 1 �� + PHONE <br /> -7 1V � ��1 Ute, ljU ��_ IlF <br /> CITYy�P3 <br /> � 57ATEe zip YJ� <br /> A Ess for fees and charges OWNER FACILITY/BUSINESS THIRD PARTY BILLING <br /> Rn.uNO ANn(OnrP+.�A NrF A rKNOwt.PnemFNT; 1,the undersigned Applicant,certify that I am the Owner,Operator,or Authorized Agent of this Business,and I acknowledge that all PERMIT FEES, <br /> PENALT/ES,ENFORCEMEA'T CHARGES and/or HOURLY CHARGES associated with this operation will be billed to me at the address identified above as the ACCOUNTADDRF.S.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 COUNTY Ordinance Codes and/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' vailable and at the same time itis <br /> provided to me or my representative. <br /> APPLICANT NAME P�LEA,S,E PRINT SIGNATURE <br /> TITLE DRIVER'S LICENSE(PHOTOCOPY REQUIRED) <br /> Approved By Date Accounting Office Processing Completed By Date <br /> 29-02-002 April 25,2003 <br />