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San Joaquin County Environmental Health Department <br /> GREEN FORM <br /> DATE MASTER �FI1LE RECORD INFORMATION "MFR" <br /> CMAnFn saosc Fog F1411 imp nNi v OWNER ID# U 1'106 �3`..�777� GSE# UNIT IV <br /> OWNER FILE <br /> COMPLETE THEFOLLOWING <br /> PROPERTY OWNER INFORMATION; CHEcKrF OWNER CvRRFNTLroNFrtewmi EHD <br /> PROPERTY OWNER NAME PHONE -7 <br /> 6LMV ` / <br /> First MI Iry a <br /> BUSINESS NAME F 13 A' 1 P Soc SEc/TAx ID# <br /> Owner Home Address �15 W-" <br /> `-" -5f- L Y 1 2005 DRIVER'S LICENSE# <br /> city Oa 16(av� RONMENT HEA STATE CIA- <br /> ZIPTH <br /> / I <br /> Owner Mailing Address JIVII ICE'S C/r` <br /> Mailing Address City State Zip <br /> 7VOF nF nwwFocwTo ^, <br /> CORPORATION❑ INDMDUAL❑ PARTNERSHIP❑ FED AGENCY❑ OTHER L11' <br /> FACILITY FILE <br /> �K- <br /> ID# 1f,33:3 <br /> f233 C �REF'D# <br /> MoUNTID# T'r7L()3 INv# <br /> COMPLETE THEFOLLOWING <br /> IS this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ No ❑ <br /> Is this an E)asTING Business LOCATION but a NEW TYPE of regulated Business? YES ❑ No ❑ <br /> BUSINESS/FAciLmt/SITE NAME LeiA <br /> /�/� 1 r b <br /> SITE ADDRESS ^) I j 3 3 ,-` , / SUITE# BUSINESS PHONE <br /> CITY -20 <br /> r/, uoJ -kv. v1 S l STATE ZIP <br /> BOARD OF SUPERVISOR Dlsmcr LOCATION CODE KEY1 KEY2 / J �3- <br /> Mailing Address if DIFFERENT from Fad/ityAddress Attention:or Care Of(opdona/) <br /> Mailing Address City <br /> STATE ZIP <br /> SIC CODE APN# O3 c O COMMENT: <br /> --7] <br /> THIRD PARTY BILLING INFO: Comp/eteif Billing Party <br /> is different from Property Owner or Facility Operator identified above. <br /> BUSINESS NAME .�^ y �u��G A I _�� ,� Attention:orCare Of (optional) M, V/] - <br /> Mailing Address Fit i PHONE �I h 1 I[ISS T fo <br /> Cnti STATE/!�lJ ZIP ✓I /D <br /> �,,SCCOUNrn^^RLW for fees and charges <br /> OWNER FACILITY/BUSINESS THIRD PARTY BILLING <br /> Rn.�.��C.a�n COMPLIANCE ACKNOWI FDrntENr: 1,the undersigned Applicant,certify that 1 am the Owner,Operator,or Authorized Agent of this Business,and 1 acknowledge that all PERMIT FEES, <br /> PENALTIES,i3NFORCE.ttENT CHARGES and/or HOURLYCHARGES associated with this operation will be biped to me at the address identified above as(he AccouYTADDRF-eS 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,l hereby authorize the release of <br /> any and all results and environmental assessment information to SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEART, ENT as soo s it is available and at the same time it is <br /> provided to me or my representative. - <br /> APPLICANT NAME d PRINT (7 <br /> / <br /> TITLE C,,yo t-- ��/ _/C�m�� DRIVER'S OCOPY RECOUIIRED) i5 I/r <br /> i .. oved BY Y Date �� Accounting Omce Processing Completed BY Date -7 15-0 C� <br /> 29-0 J02 April 25,2003 <br />