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San Joaquin County Environmental Health Department <br /> GREEN FORM <br /> DATE ��/�(o �� <br /> MASTER FILE RECORD INFORMATION "MFR" <br /> SHAnFn APrAG FOR FHn usF fIN�v OWNER ID# CASE# UNIT IV <br /> OWNER FILE <br /> COMPLETFTHE FOLLOWING PROPERTY OWNER INFORMATION: CHECKrF OWNER CURRENYLroty rLEwrrH EHD ❑ <br /> PROPERTY OWNER NAME PHONE <br /> First t� MI Last <br /> BUSINESS NAME _ II It/ �,r–� y7 DO n /� O�r Soc SEC/TAx ID# <br /> Owner Home Address j� DRIVER'S LICENSE# <br /> City STATE ZIP <br /> Owner Mailing Address b T�. [es <br /> Mailing Address City o r ^J St'$AA ZtP O I 00 <br /> PE GE QWNFPCHTP <br /> CORPORATION INDMDUAL❑ PARTNERSHIP❑ FED AGENCY❑ OTHER❑ <br /> FACILITY FILE <br /> FACILITY ID# WMkS6Lk77EF <br /> ID# ACCOUNT ID At /� (� � INV# <br /> �p�S1 <br /> COM <br /> PLETF THE FOLLOWING NF RMATION' <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 ❑ No ❑ <br /> BUSINESS/FACILITY/SIITTE NAME S"T- <br /> C/ 1 <br /> SITE ADDRESS . C SUITE# `I6 BUSINESS P O <br /> CITY �To G �To Jiw'ZIP C)'5 2 o2 <br /> BOARD OF SUPERVISOR DLSTRICT LOCATION CODE KEPI KEY2 <br /> Mailing Address ifDIFFERENTfrom Facility Address Attention:or Care Of(optional) <br /> Mailing Address City STATE ZIP <br /> KC.DE 11 APN# I[EME-; <br /> THIRD PARTY BILLING INFO: Complete if Billing Party is different from Property Owner or Facility Operator identiFed above. <br /> BUSINESS NAMEJ Attention:or Care O�,f j/optional) <br /> �Q M / < C_C e Vi TS W I L L14 fs <br /> Mailing Address 2- L f `t( A AV <br /> /G 10 I P 2( 4-25 35 <br /> CITY lO Y H v ZIP e--)=5-+2.D <br /> arca NiAaaocsv for fees and charges OWNER FACILITY/BUSINESS THIRD PARTY BILLING <br /> Ru t INr.non f'nrert.tnncE A(7KNowLEnGMFNT: 1,the undersigned Applicant,certify that I am the fhvner.Operator,or Authorizer/Agent of this Business,and 1 acknowledge that all PFRMn FFF4, <br /> PENAr.T ,ENFORCEMENT CH.IRGE•S and/nr HouRLYCHARCES associated with this operation will be billed to me at the address identified above as the ACCOUNTAUDRES'.S for this site. 1 also certify that <br /> all information provided on this application is true and correct;and that all regulate(]activities will be performed in accordance with all applicable SAN.IOAQUIN COUNTY Ordinance Colles 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 ab facility/site address,I herebv authorize the release of <br /> any and all results and environmental assessment information to SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DF.PART" T ass sit is available and at the same time it is <br /> provided to me or my representative. <br /> APPLICANT NAME tt PLEASE INT SIGNATURE <br /> 1 � 1 I U In/I � i D�_S <br /> TITLEIi ent DRIVER'S LICENSE# <br /> \1!L C,l� r �' (PHOTOCOPY REQUIRED) VL S OO G•� Q V <br /> Approved ey Date Accounting Office Processing Completed By N Date 1 <br /> 29-02-002 Apn1 25,2003 <br /> COVIDENTIAL <br />