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t t <br /> San Joaqui unty Enviro ntaI Health Department <br /> I �� 9� � GREEN FORM <br /> DATE 5t �� � MASTER tE RECORD INFORMATION "MFR" <br /> TURN <br /> t� UNIT IV <br /> SLLS�areae w Rrin��Farr V - <br /> OWNER FILE <br /> 0LVMMTHEF0L10WrNGP PERTY OWNER INFORMATION;___ <br /> Urraro OWNER CVgRF1Vny0NFLU'WITN END ❑ <br /> PROPO(TT OWWR NAM PHOT e <br /> First Mf Last <br /> sUSDEW NAFAEGA+2.roRNSA DEQA4ZTt�ENT' vF wpri�"`c-k- iD��,sov2CES S(X SEC/TAX ro# <br /> Owner Home Address DRTV Rt LrCENSE# <br /> Olty STATE ZIP <br /> Owner Ma"Address 311 b E��ml N p <br /> Address Ott` SAC(Z mE JV1 b �� GA tip �S&Z I <br /> COR)OMTFpt❑ INorvmluL❑ PART1 "tts' OTMM❑ <br /> FACILITY FILE O O 3 O <br /> Is tills a NEW Businm LOCATION not previously regulated by Uie ENVIRONMENTAL HEALTH DEPARTMENT? Yrs ❑ No Z <br /> IS tills an ExmTm Business LOCATION but a NEW TYR of regulated Business? t YES ❑ No <br /> SU91OW/FACUTT/SVENANE <br /> SITE/WortE/$,, ` M� Stun# 6ttsnv�5 Pttorff <br /> MyL�}r�ti20P/J7DG�T6��t KIsSpALE COSTATE ZIP — IIJI <br /> I <br /> •r -�' <br /> F Wbv Address ffAV-�. rlitam Fa&1tyAa&V" Atbention:or tare Of(option/) <br /> Ma"Address City ---- STATE ZIP --� <br /> z v"x + <br /> THIND PAIeTtt BILLING INFO: Complete if Billing Party is differentfiom Property Owner or Facility Operator idendf,4ed above. <br /> MIMNEWNAW -� Attention:orCwe Of (ap6o sag <br /> +-U RD W657,- <br /> Mahler,Address L)OD RR oA w)v S Zoo* Pr,or.E 5/6 -Z,68 •0 l <br /> CITY QCA STATe 7 9y607 <br /> jG Z for fees and charges OWNER FACiuTY1BUSINESS THIRD PARTY BILLING <br /> Hes llNf:ANTI COasrt SAN('F ArXNnWllnr:MFNT• 1,the undersigned Applicant,certify that i am the Owner,Operalw,or Aurhorized Agmr of this Business,and I acknowledge that all PERAOT FFFJ, <br /> PFN.s MS,FNF0RCtxe"?CHARGES and/or HOURLYCHARG.E.T associated with this operation will be billed to me at the address identified above as the Arr»nN'TADDAUc for this site. I 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 JOAQWN COUNTY Ordinance Codes 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 above facility/site address,1 hereby authorize the release of <br /> any and all results and envinntnenlal assessment information to S-AN JOAQULN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as availab d at the same time it Is <br /> .provided to one or my repremtstive <br /> PLEASE P11. <br /> APPLICANT NAME [-+60MGt qi)5 - SIGNATURE <br /> TI"E RINIER'S LICE'q5S0c,-47-e �6FNE E� °PMf TT " - <br /> App..d h .rJ-!� mft ! y t i� A[oouttlhsp txRot ft..Wq C pied By <br /> 29.02-002 April 25,2003 <br /> CV-'r <br /> A L <br />