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San Joaquin County Environmental Health Department <br /> L <br /> GREENFORM <br /> DATE ATION "MFR" <br /> �- �o/O MASTER FILE RECORD INFORM IUNIT IV <br /> SHADGAEHO Q'%Py4y OWNER IOM 1 CASE# <br /> - - OWNER FILE l <br /> Cxaculf OWNER CUMENnI`om F/LE*WN EMD <br /> COMPLETE THEFOLLowNG PROPERTY OWNER INFORMATION.' <br /> PROPERTY OWNER NAME /QQ O/�.0 ST/P.t .G % C7dx�o,era �/off PHONE <br /> WN <br /> First Mt Last <br /> BuatNEas NAMESoe Sec l TAx ID# <br /> %O d OAK oT7,Q.�.E i C'v.G'�v,e A i io rt/ <br /> owner Home Address <br /> DRIVEA�s LIcaN3E M <br /> �r/d /!')�. .EiC/C� I�/� '� _ _ - --- - <br /> �� �/�l J c/ STATE LP <br /> city "//V'C 4:""o �%/7�2 <br /> Owner Mailing Adds .4 ,6110 /✓�a NT6✓ m t.e J ✓•r Nvk <br /> Mailing Address city CiZ 7—me fyA j� z�n ,Zy 8/y <br /> ffrEFOWIFfigillp <br /> CORPORATION immouAL❑ PARTNERSHIP❑ FED AGENCY❑ OTHER❑ <br /> FACILITY FILE <br /> E <br /> ION CROSS REFID# J AOcou NTIO#_ -- INV# <br /> COMPLETE THEFOLLoww BUSINESS I FACILITY/SITE INFORMATION: / <br /> Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPT.? YES (}f No ❑ <br /> Is this an ExIanNO Business LOCATION but a NEW TYPE of regulated Business? YES ❑ No p/ <br /> \ BusiNE9a1FACILITYISITE NAMEr • Z-" <br /> Sof�• r� �u C'el •�'i"n q on ti( Uh�or <br /> SITE AtmRE93 .33 //4/4/ � /)./��� .gURE# BUSINESS PNDN <br /> Crit JTo C,e ;r-0 4" �i 111777��� Y V STATE�f� ZIP <br /> [!77! <br /> SUPEFMSOR DISTRICT LocanoN Com KEY1 KEY2 <br /> Mailing Address ND/FFERENrhwnfeo0yAddr@W Attaltion:or Caro Of(optlowl) <br /> Mnlling Address City STATE ZIP <br /> SIC COUE __ - APNN — C—ENr: —--.--- I <br /> THIRD PARTY BILLING INFO: Complete ifBilling Party is different from Property Owner or Facility Operator identirtedabove. <br /> BusiNEsaNAME Attention:orCareOf(optional) <br /> ✓biCi�1,[ �'ou.�✓c°ic aL C/71/`o.�N/�9— A.��>>i�✓�,5���a>�✓€ o6Ficjt d< SNE Cdou�T.S <br /> Melling Address „7.Z$5� / ON i��e/u `. a o o PHONE&/8 ` <br /> CITY �l k' STATE aoq ZIP /1se)7 <br /> dG numrAGOREw for fees and charges OWNER FACILITY/BUSINESS THIRD PARTY BILLING <br /> 01 LLING A40 CDNlrl,b\N;y,AC KCIQW(BDGh1 ENT: I,the undcrAgned Applicant,certify that I am the Owner,Oparotor,or Arithorired Agent of this Business,and I acknowledge that all Pt-"Rdenr FHka; <br /> PFNALTIRi ENF0RCFA1ENr C1L4RGE.r And1or IIOURLr CU.1RGEs associated with this operation will be billed tome at the address Identified above;U the ACCOUNT1100RILSS for thio site. 1 also certify that <br /> all information provided on this application is true:and correct;and that all rel,ulatcd activities will be performed in accordance with all applicable SAN JOAQUI4 COUNTY Ordinance Codes nndlor <br /> Standards and STATS and/or bY.DFRAI,I.aws 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 SAV JOAQUIN COUNTY ENVIRONMENTAL REALTII ne°"u•r,M nrr as soon as It Is available and at the same dude It is <br /> provided to me or my representative. <br /> APPLICANT NAME rhe q d)/P /�E.�!A/ PLEASE PRINT <br /> SIGNATURE <br /> TITLE �/✓✓/f'U�l�rCe✓% ANS -7— DRIVER•SLICENSEM A A C,"S7 1 4 2 <br /> P 12TQ44PYPF.QIIIRE01 <br /> Approved By Onto Aocounhng Office Processing Completed By p <br />