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San Joaquin County Environmental Health Department 1b <br /> 0y I O GREEN FORM <br /> DATE r MASTER FILE RECORD INFORMATION "MFR" <br /> SHencn ee Fec Fne FHn ncF nHi v OWNER ID# CASE# UNIT IV <br /> OWNER FILE <br /> COMPLETE THE FOLLOWINGPROPERTY OWNER INFORMATION; CHECKIF OWNER CURREHrzroNPufwrrH EHD <br /> PROPERTY OWNER NAME PHONE <br /> f First MI Last <br /> BUSINESS NAME U, a 1 r— 1 '0 S T* �� P O �n of SOC SEC <br /> /TAX ID# <br /> Owner Home Address +V ' PV DRIVER's LICENSE# <br /> City STATE ZIP <br /> Owner Mailing Address D . t s !J 1. t {x O it. <br /> Mailing Address City n! �r�IVO�1` �19 <br /> r�sta /1 /� Zip 0 I 8 <br /> TYDF nF nwUERsHip I VI t"t <br /> CORPORATION INDIVIDUAL❑ PARTNERSHIP❑ FED AGENCY❑ OTtiER❑ <br /> FACILITY FILE <br /> �—ID# CROSS REF ID# ACCOUNT ID# INV# <br /> COMPLETE 7HEFOLLOWING BUSINESS / FACILITY I SITE INFORMATTON.- <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/FAcniIY/SITE NAME Kj I F� cT' <br /> SITE ADDRESS I . ` n C SUITE# ' USINESS O <br /> CITY �To e,- <br /> K.To t-,4J �4J� X15 2 02 <br /> BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEY1 KEY2 <br /> Mailing Address ifDIFFERENTfrom Facility Address Attention:or Care Of(optional) <br /> Mailing Address City STATE ZIP <br /> [SIC CODE IH:� <br /> COMMENT: <br /> THIRD PARTY BILLING INFO: Comp/ete if Billing Party is different from Property Owner or Facility Operator idenb'fied above. <br /> BUSINESS NAMEJ i Attention:orCareeO�f loptional) <br /> �S l. T; W f L G.1 A (— <br /> Mailing Address -ALLUVIAL v AVC,. <br /> # 101 <br /> I0I P 2&4_25 35 <br /> CITY T--' 12--a5 rfo ��jj++11 4E ZIP q�1-20 <br /> *d <br /> Accow ^^B&9 for fees and charges OWNER FACILITY/BUSINESS THIRD PARTY BILLING <br /> Bu.t.iNc Ann('OM1IPLL�NCF:Ar'KNoW1,FDGmr'.NT: I,the undersigned Applicant,certify that I am the(honer,Operator,m-Authorized Agent of this Business,and I acknowledge that all PERM17 FEFS, <br /> PEaAt.nEs,ENt'uer'EnfENTc1'1ARcES and/or NouRFrCHARGES associated with this operation will be billed to me at the address identified above as the ACCOUNTAnt>RF.cc 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 propertylocated at the abo facility/site address,1 hereby authorize the release of <br /> any and all results and environmental assessment information to SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTAI T as s s it is available and at the same time it is <br /> provided to me or my representative. • <br /> mac"_5 <br /> APPLICANT NAME PLEASE INr SIGNATURE <br /> � I <br /> TITLE 1 Q e s i c{enfi D HO`Tocovr RER'SCO IR D) &D L G <br /> Approved By lJ� Date Accounting Office Processing Completed By Date <br /> 29-02-002 April 25,2003 <br />