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C . <br /> San Joe ,.,in County Environmental Health Department <br /> DATE 8I_ o/v MASTER FILE RECORD INFORMATION "MFR" GREEN FORM <br /> SNAor,omfmrori EHD.U{ O♦_IW' OWNER IOM CASE UNIT IV <br /> 0wNQt FILE <br /> COMPLETE TNEFoLLowlNG PROPERTY OWNER INFoRMArrow CHEcxh�OWNER CvRRrsn rowsu.f wrrH EMD E <br /> PROPERTY OWNER NAME /00 oll,< STiP,t.0 % c7Ore/°o.e.q ;,"/Oi✓ PHONE <br /> r <br /> First M! Last <br /> 903INEWNAME j00 DArN oT7.P.t✓.Ei ouz lo(f),eFlilo SocSec1TAxID$ <br /> Owner Horne Address CInR. Mfg y DItIVER'6 UcENaE$ <br /> city C tyU.0 !�j;rq'e 6-x D L/ STATE ZIP <br /> Ownw Malting Addrw ,�/��tJ /y Ja,yTG o m t,e y ✓,E/S/L/,t <br /> Mailing Address City X TN,c.f v y Sh " /771j Zp <br /> CORPORATION INDIVIDUAL❑ PARTNERMP❑ FED AGENCY❑ OTHER❑ <br /> FACILITY FILE <br /> FACILITY ID$ k2t CRoss REF ID N AccouNT ID N 2 / / �s— INV$ <br /> ComPLETETHEFOLLowNG BUSINESSI FACILITY/SITE/wmmriom- J fol. U <br /> Is this a NEw Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPT.? YES L4! No ❑ <br /> is this an ExisTiNO Bualness LOCATION but a NEW TYPE of regulated Business? YES ❑ No Q/ <br /> 81.18INE331FActuTYfSireNAME <br /> SITE AOORE33 �J /. rn� SUITE$ BUSINES8 PHO'0('Y)yG/- <br /> CrryJ <br /> D�rl�l <br /> �/ STATE�rA ZJP <br /> — / <br /> .- <br /> BoARDOFSuPEavI3OR0isrRior LocnnoNCooE KEY1 FEY2 n„ <br /> Mailing Address ND/FFERENrfr m Fao11*Add we Attsntlon:or Carr Of ftspllarb) �1 <br /> Malltng Addreaa City STATE ZIP C' <br /> sic CODE <br /> J[A�P $ CDaaMtxr: <br /> THlnb PAwry BILLING INFO: Complete ifBilling Party is different from Property Owner or Facility Operator identified above. <br /> BU81NESa NAME Aden fort,orCarreee Of Bop/ffixial) <br /> -�uDl���i,c C'ou/✓c°/c of �q.�/�o.e�✓��— �I���/i✓/s i��r�✓� oFFi�.� of SNE Cdo u�TS <br /> M"1111-9 " a 5� �/ o �� a o o PHONE <br /> rATY .(Jae-9 irq Alec STATE(9/9 ZIP 17/so T <br /> 9Ld1) for fees and charges OWNER FACILITY/BUSINESS THIRD PARTY BILLING <br /> MILLING AND COMPI.IANCt:AC KNOWIADGNIENT: 1,the undersigned Applicant,certify Ihat i am the Owner,Olxrator,or Authorized Agen(of this Huslness,and I acknowledge that all PAY00T rNES, <br /> PE,xv.n S,ENroxctwEivrCmArss and/or 1/011aarCIIARG.a associated with this operation will be billed tome at the address Identified above m the AcrouwAyDRAS for this site. 1 also certify that <br /> all Informatiou provided on this application Is true and correct;and that atl regulated ActMties will be performed In accordance with Bit applicable SA.V JOAQUIN COUNTY Ordinance Codes and/or <br /> Standards and STATE and/or hkDE%%Laws and Regulations. As the undersigned owner,operator,or agent of the property located at the alcove facility/site address,I hereby authorize the release of <br /> any and all results and environmental assessment Information to SAN JOAQUIN COUNTY ENVIRONMENTAL IIEALTj)�CRAIr T ENT as soon as it Is avallabie and at the some time It is <br /> provided to me or my representative a �� <br /> APPLICANT NAME ",q 1)/1 PLEASE PRINT ���~��' <br /> f-'f/ SIGNATURE 1� <br /> TITLEv��✓/�V ���A ,/�-7- <br /> DRIVER'S LICENSE$ <br /> 7 -kat qM REQUIRED) L <br /> Approved Uy Date AocounUng Office Procaasing Completed Dy Dat. <br />