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San Joaquin County Environmental Health Department <br /> GREEN FORM <br /> DATE MASTER FILE RECORD INFORMATION "MFR" <br /> Gwennn ea Fac ono FI-In—F nw„v OWNER ID# 2-v-v CASE# UNIT IV <br /> LLLL OWNER FILE <br /> COMPLETE THE FOLLOWING PROPERTY OWNER INFORMATION; CHECR'rF OWNER CuRREN7LYONFILEwr7nEHD ❑ <br /> PROPERTY OWNER NAME PHONE <br /> First M/ Last <br /> BUSINESS NAME SOC SEC/TAx ID# <br /> Owner Home Address O DRIVER'S LICENSE# <br /> cityO N F- STATE ZTP to 510 o <br /> CA <br /> Owner Mailing Address SAM5 As <br /> �y A Ia4 <br /> yff <br /> Mailing Address City State Zip <br /> TVUF nF nwNFRcwm <br /> CORPORATION❑ INDIVIDUAL❑ PARTNERSHIP❑ FED AGENCY❑ OTH-x <br /> FACILITY FILE / <br /> FACILITY ID# U3`43 CROSS REF ID# I T <br /> ACCOUNT ID# Q�1 2� INV# <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/FACIl1TY/SITE NAME <br /> SITE ADDRESS C n ,/� SUITE#" BUSINESS PHONE <br /> CITYV 1 T f STATE6?j— Zip 1 5 Z <br /> BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEYI KEY2r� <br /> Mailing Address ifDIFFERENTfrom FacilityAddre s Attention:or Care Of(optional) <br /> Mailing Address City ^7 STATE ZIP <br /> SIC CODE APN# C)Z ,r,✓T 10 t) I COMMENT. D O (( G <br /> THIRD PARTY 13ILLING INFO: Completeif Billing Party is different from Property Owner or Facility Operator identified above. <br /> BUSINESS NAME Attention:orCare Of (optional) <br /> Z LEN <br /> Mailing Address OOO O A 2 <br /> 60 <br /> PHONE LG <br /> 12 <br /> CmATE zip <br /> Vr� <br /> LJ Ar-L!' 100, VfJt CA ' 1i60--5L- <br /> errninvr ennv�cc for fees and charges OWNER FACILrrY/BUSINESS THIRD PARTY BILLIN <br /> Ru i rvr.ANn('Omer, L ACK2jaAL DGNIFNT: 1,the undersigned Applicant,certify that 1 am the Owner,Operator,or Authorized Agent of this Business,and 1 acknowledge that all PERh1IT <br /> PEAALTIfS,E.NFORCEAfE.N7CH.tHGF. and/or HOURLYCHARGES associated with this operation will be billed to me at the address identified above as the A.CCOUVTAnORecv 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 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 SM JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPART ENT as soon as it's available and at the same time it is <br /> provided to me or my representative. <br /> _ <br /> APPLICANT NAME PLEASE PRINT p ��j �_ g rJb SIGNATURE <br /> TITLEDRIVER'S LICENSE# <br /> > S%7 <br /> ak3 � (Y)A rf��Nz- (PHOTOCOPY REQUIRED) lg 3`3 g <br /> Approved By Date Accounting ice Processing Completed By Date Z <br /> 29-02-002 April 25,2003 <br />