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San Joaquin County Environmental Health Department <br /> GREEN FORM <br /> DATE MASTER FILE RECORD INFORMATION "MFR" <br /> SHADFDARFA9 FOR EHD WE ONLY OWNER to# CABE 9 UNIT IV <br /> OWNER FILE <br /> CoMPCETE 7,HEFoLLow1NGG P ROPERTY OWNER INFORMATioN: CHLcx lF OWNER CURRENTL r o>r nLE w17H EH D <br /> PRopatTYOwNERNAME �L I ICK f_fQNF Y PHONE \7 ,;?60 <br /> First I MI I <br /> I Lasa 11 p <br /> BustNEss NAME ., S�r1 Q—t MSA~ rd Tr. SGROWTAX IDO X3-43V&ZNWW6 <br /> Address C S J fJ� O hiSF R��1 �y DavcR'sLIcENSE9 <br /> city L. r STATE FL zj" 3 3Y.T� <br /> Dw arMalDnp Addre.. <br /> Mailing Address City Slam 21p <br /> CORPOMnON❑ INDIVIDUAL❑ PARTNERSHIP❑ FEDAaDicycl O-TTiEA <br /> FACILITY FILE <br /> FACIUTYID0 �N CnossREF ID9 ACCOUNT ID f/ � b INV# <br /> I l Q v_C lP <br /> COMPLETE THEFoLLow/NG BUSINESS 1 FACILITY 1 SITE INFORMA noN.• <br /> Is this a Ndww Business LOCATIDN not previously regulated by the ENVIRONMENTAL HEALTH DEPT.? YES ❑ No ❑ <br /> Is tills an ExisriNG Business LOCATION but a NEW TYPE of regulated Business? YES ❑ NO ❑ <br /> BUsINEsWACILRY/SrrENAME VVA( �t-ki <br /> SIrEADDRESS �J 1w/. Y�I / WA SurrE# BUSINESSPHONE <br /> C- STATE C-A ZIP <br /> BOARDar6UPERVL90l"•R,OISMOT LACATIONCODE KEY1 „ I KEPI <br /> Moiling Address dDlFFERENrfrom Fst:LWAddros+ tl Attention:or Cam Of(optional) <br /> MDUIngAddress City STATE ZIP <br /> SICCCOE APN9 /,J •�J . ��, CoMMEwn <br /> THIRD PARTY BILLING INFDI Complete lifBilling Party is different from Property Owner orFacliity Operator identiriedabove. <br /> BUSINM3 NAME/-y ��) �{F.Y 12/^•S AftanUarL orCOru Of(opbanal) <br /> MoDingAddreaaKVla-`'N� 011 CGtt t Sk Z(L{ PNONE/'2S_ q _ 2 U <br /> Cm 'Flat&IIcek.-41 Ln STATE( ZIr <br /> ALxOUNLADOBE53 for faos and charges OWNER FACwTvIBUSINESS THIRD PARTY BILLING <br /> Ntt t tNr AND COWMAN"ArTCNnu'IT1101ENT: 1,the undersigned Applicvnl,certify that I am the 0%. ,Opanrer,or,IuLAorC1d Axed or"Dusinty,and 1 ndk lcdgc that au PFJUtrr FEEs, <br /> Pix,to ET,ENFURCELfENr CnAAG-T and7or IIOIIAL I'CFIARGES usodaled with this operation wi0 he billed to me at Uhc nddr idwtified niewe as the,tn MhTj AARECt'ror this site_ 1 also certify that <br /> all information provided oa this appiimiion Is ime and correcr and that all regulated octvidee mill be prrformel in accordance with all appliahle SAN JOAQUIN COUNTY Ordm m Coda and/or <br /> SLandards and STATE and/or FIArRAL Lucas and Reguletions.As the undersigned mmcr,operator,or agent or the property located et Lit bove fatality/site addresk 1 hereby oud—tu the rtl—.f <br /> any and a0 rteuln andumvlronrnen tela+mrnl infestation in SAN JOAQUIN COUNTY ENVIRONNIENTAL IIEAL'rid DE PA A1EP7T w soon hu it is ^ <br /> ara14so <br /> le/+{►nd of the me time it Is <br /> providd to me or Noy rtpracntativ� �����I �_. <br /> n \ LEASE PRINT SIGNATURE <br /> APPLICANT NAME <br /> TITLE /�� DRIVER'S LICENSE# / -0 .y`�,/&0/� <br /> t,,,,� IPHOTOC OPV RE'QUIREp) �-f r l/ <br /> Apprwad By Data AeeounUnp ORlee Proeaeaing Complalnd By Oats <br /> 29 0' 10112/07 h1ASTLR FILE RLCORI)-GUEN <br /> CONFIDENTIAL <br />