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r <br /> San Joaquin County Environmental Health Department <br /> GREEN FORM <br /> DATE MASTER FILE RECORD INFORMATION "MFR" <br /> SHAncn ARFAc Fna FHn 1r;E 3hj Y OWNER ID# 13-,-a CASE# UNIT IV <br /> OWNER FILE <br /> COMPLETE THE FOLLOWING PROPERTY OWNER INFORMATION; CHECKIF OWNER CuRRENrzroNFrcEwmr END ❑ <br /> PROPERTY OWNER NAME h-L-- j uA �RaCG�'I ,I.G (7uE PHONE <br /> First MI Last <br /> BUSINESS NAME n Soc SEC/TAx ID# <br /> owner Home Address 3 d DRIVER'S LICENSE# <br /> city C— 'Nn STATE ZIP <br /> Owner Mailing Address 1 e <br /> Mailing Address City A �. S zip 9S <br /> TYPE nF n NFRCHIP <br /> CORPORATION❑ INDMDUAL m PARTNERSHIP❑ FED AGENCY❑ OTHER❑ <br /> FACILITY FILE <br /> FACILITY ID# I 3 l f CROSS REF ID# ACCOUNT ID# 2 �3 INv# <br /> Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ No ❑ <br /> Is this an EXISTING Business LOCATION but a NEW TYPE Of regulated Business? YES 13 No ❑ <br /> BUSINESS/FACILITY/SITE NAME /� / t <br /> SITE ADDRESS L� �/��...LLL/// SUITE# BUSINESS PHONE <br /> rd P-ek <br /> CIT,, � �-M n _^ � STATE ZIP <br /> BOARD OF SUPERVISOR DISTRICT TJ►r LLocoCA�TIOVN CODE KEYZ KEYZ <br /> Mailing Address ifDIFFERENTfrom FactlityAddrtess Attention:or Care Of(optional) <br /> Mailing Address City /� STATE ZIP <br /> SIC CODE APN# 0'�21,I C)O COMMENT. D O `1 <br /> THIRD PARTY BGILLININFO: Completed Billing Party is different from Property Owners or Facility Operator identified above. <br /> BUSINESS NAME Attention:orCare Of (optional) <br /> P ST rG% SAV966247 <br /> � <br /> Mailing Address 1000 Q Rip Wft S —7 a O D PHONE G lo arO —U <br /> CITY OAKLAND 1� ST <br /> ATE ZIP ^40� <br /> rre <br /> eccauAnnRacc for fees and charges OWNER FACILITY/BUSINESS HIRD PARTY BILLING <br /> BU t TNG ANI)Conirt tANcF ACKNOWFFnc. <br /> . NiFNT: 1,the undersigned Applicant,certifv that 1 am the Owner,Operator,or Authorised Agent of this Business,and 1 acknowledge that all PER,1HTFEFS, <br /> PENALT/FS,ENFORCEMENT CHARGES and/or HOURLY CHARGES associated with this operation will be billed to me at the address identified above as the ACCOrATADDRFSS 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 SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my representative. <br /> PLEASE PRINT_ � 2 <br /> APPLICANT NAME ��t A�� � J�N��niC SIGNATURE <br /> I3� L� <br /> TITLE DRIVER'S LICENSE# p 1 ILI <br /> p p Q <br /> ��n '� -C"-[-" ��q('J�-v�t�•� (PHOTOCOPY REOUIRED) <br /> Approved By Date Accounting Office Processing Completed By Date <br /> 29-02-002 April 25,2003 <br />