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San Joaquin County Environmental Health Department <br /> DATE MASTER FILE RECORD INFORMATION "MFRGREEN FORM" <br /> SHADCO ARFA9 FOR EHD'Jti ONLY OWNER 111W CASES UNIT IV <br /> OWNER FILE <br /> CoMPtEnF.FrHEF=.ow1NoPROPERIY OWNER INFORM rim.' CHrcR,F OWNER CuRRevriyaNFmEwnH EHD <br /> PROPERTY OWNER NAME PHONE <br /> Fdw Mf Lasf <br /> 81.181NES5 NAME SDc SEcITA%ID* <br /> 1 �•i�/ll�'F'^CJi� L 7 a S f /``' q'A'} t� <br /> own'thr Home Addraw DRIVER'S UMNAE* <br /> Clly STATE ZIP <br /> Owner Mailing Addrim Aj t <br /> MallingAddrelaOilyStaffGZ Zip <br /> S ocl�yr : <br /> CORPORATION INDIVIDUAL❑ PARTNERaHIP❑ FEDAGENCY❑ OTHER❑ <br /> F <br /> FACILITY FILE <br /> ACILITY ID# ROaB F ACCOUNT ID# INV# <br /> CONKETE MEFOL LOwiw BUSINESS I FACILITY 1 SITE INFORMATION: <br /> Is this a New Business LOCATION not previously regulated by the ENVIRONMENTAL_HEALTH DEPT,? YES ❑ N-A <br /> Is this an EXISTING Business LOCATION buts NEWTvPE of regulated Business? YE. ❑ ND <br /> BUSINESsIFACILITYl51TE NAME � -f V t J <br /> SREADDREss .�C/— y�— Su1TE11 E58PHONE —t--p <br /> CrtY /h STATE, LP <br /> BOARD OE SUPERVIBOR DISTRICT ( LOCATION CODE Kerf 'l KFY2 <br /> Mail ingAdd raanlfDIFFERENrfrom FaciOlyAfddmss Atiadion:or Care Of(optlona/) <br /> Mailing Addmaa City STATE —ZIP <br /> SIC APN# - (Z 7 COMMENT. <br /> THIRD PARTY BILLING INFO: CompleteifBilling Party is different from Property Owner orFacifity Operator identiffedabove. <br /> Attention:or Care Of(opHwxitV <br /> IjQ61NE5S NAME 1 �J <br /> Malting AddreseC — / •t y� 'f'— PHONE V—el) <br /> Cm' ( / STATE C4 ZtP <br /> Acc12uATAna9E-for fees and charges OWNER FACILITY/BUSINESS THIRD PARTY BILLING <br /> BILLING AND CONMIANrf ACt(NowLynCMRNT: I,The undcraigned Applicant,certify that I am the(honer,Operawr,ar ADiltnrized Agent of this Ilusinem and I acknowledge tint all PCRAff FEET, <br /> rENALT=,ENroRcHAIEm'CIGIRGHS andlor HOutmY CIL4RQEv associated with this opemiian will be billed In ram at the address identified above as the AccuifNTAnym.-,1'S for this ova I alto certify that <br /> nil information provided on this application is tme and ro—t;and that all regulated nctivities will be performol in uxordance with all applicable SAN JOAQUW CDuwry Ordinance Codes and/or <br /> Standurds and STATE andlor F¢DEBAL Laws and Regulations.As the undessigoed owner,operatur,or agent or the property lamted at the above faCdity/site address,I hereby authorise the release of <br /> any and all results and environmental assessment information to SAN JOAQUIN COUNTY ENVHtONMENTAL HEALTH DEI ly TAfI:NT ai soon m it is avAilnhle Rml at the same fime it is <br /> provided to ma nr my mpresentatim 1 Q^ <br /> PLEASE PRINT SIGNATURE <br /> APPLICANTNAME —p;,t,,c�p ��R�j4 <br /> TITLEl : DRIVER'S LICENSE# <br /> -ONmc,4or O}. - \O-KA oaeAt ktenJ qx �oAn TlotllsZ (PHOTOCOaYREOUIREDI <br /> Approved By Oo1e Aceou❑tinp Office Preces=Inp Completed By Dale <br /> 129-02 10/12/07 MASTER RLE RLCOIW-GRL'LN <br />