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DATE San Joaquin County Environmental Health De„ artment <br /> �lGREEN FORM l I MASTER FILE RECORD INFORMATION `" MFR" <br /> OWNERID# CASE # UNIT IV <br /> OWNER FILE <br />{ COMPLETE THEFOLLOWINGPROPERTY OWNER INFORMATION: CHECKIF OWNER CURREnm.voNrTtE wrnT EHD <br /> PROPERTY OWNER NAME PHONE <br /> FlrsfMI Last <br /> BUSMEss NAME n r C ti /f - ' /nM� � SDCSEC / Tm ID # <br /> Owner Home Address ? i � <br /> Ail I. <br /> City llr � . ��J �L DRNER'S LICENSE # <br /> �v /� ( t`y 4 `7 STATE ZIP <br /> Owner Mailing Address / <br /> Mailing Address City State ZIP <br /> OF OWNEi <br /> CORPORATION ❑ INDIVIDUAL ❑ PARTNERSHIP ❑ FED AGENCY El OTHER ❑ <br /> FACILITY FILE <br /> FACILITY ID. # CROSS REF ID # AC[OtIM ID At Inv# II <br /> OMPLETETHEFOLLOWING NFORMAmome <br /> Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENP YES ❑ No ❑ <br /> Is this an E)(1STING Business LOCATION but a NEW(TYPE of regulated Business? YES ❑ NO ❑ <br /> BUSINESS/FACILITY/SITE NAME G� <br /> SITE ADDRESS <br /> V J U # BUSINESS ME� <br /> Cm STATEC+ <br /> ZIP <br /> BOARDOPSUPERVISORDISTRICT LOCATION CODE KEYt KEY2 <br /> Mailing Address ifDIFFERENTfrom Facr/ityAdd ess Attention: or Care Of (aptionalt <br /> Mailing Address City STATE ZIP <br /> SIC CODE APN # COMMENT: <br /> THIRD PARTY BILLING INFO; COrrlp/ate if Billing Party is differentfmm Property Owner or Facility Operator identified above. <br /> BUSINEss NAME I y-YI UfYG rt >vtts.L an (� n _ Attention: orcare Of " N"OnaQ <br /> ({ G1/\ti � � � � (7 C hw)L � 1f - <br /> Mailin9Address 7((� / A.I.J n �C O PHONE Z <br /> CITY 5 \ � � 'F-a fr\ V\4 V l ei j� STATE /' L� ZW <br /> A for fees and Charges OWNER FACILITY/BUSINESS 1. THIRD PARTY BILLING <br /> 1mAJNG ANn CnnnR Gy. ACKXDR1EDGA1E.NT; I, the undersigned Applicai certify that I am the Owner, Operator, or Authorked Agent of this Business, and I acknowledge that all Poaaan-F 5, <br /> PENALTIES, ENrawEwm CHARGES and/or HOUEIY(ottaGES associated with this operation will be baled tome at the address idendged above as the ATr nrvrApptimc 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 ADEPM1NT as soon as available end at the San a dme it is <br /> provided tomeormyrepresenta eAPPLICANT NAMEp /' PUSIGNl.r-t/LgC.<et, 11ec� 1n� IVv1 "� <br /> TITLE DRIVER'S 110ENSE # <br /> (PHOTOCOPY REOUIRED) <br /> Appeased By Data Aaouunting Once Processing Completed By Date <br /> 29-02 �0 � 25, 2003 ,fj � 6 _ 1 <br /> L / S � `f <br />