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Mar. 22 04 03: 40p PUH Fina A <br /> 925-314-3854 p. 3 <br /> 0/22/2004 14:29 FAX 209 9480621 \ 00� lQ1 00Z <br /> Vk <br /> 2 <br /> F " rr GREEN FORM <br /> DA <br /> TEMASTER FILE R F��FORMATION MFR <br /> " .1. 31 <br /> UNIT IV <br /> L)w DDI l Si�j OWNER FILE <br /> OrEcxJF OWNER CURRE/vttroAr r7tf WlTt/ETiD <br /> co,sfPLE7rrH-=mLLoATNGPR0P1ERTY OWN UNFORNATZOV <br /> PHow <br /> Paovexry Dovnt�t: <br /> NAME � <br /> F/rsr Ml IBd( <br /> Busmiss HAM Q '{' l©✓1. L 5l-EC/TAX Wis <br /> Avner Home Address I Q 24-5 <br /> City L 0.A res STA m _ <br /> CWner nanlnPAdA— <br /> Malling Address Cite <br /> 7V VF no rnrruFvailP <br /> ❑ ta.er..Fn�..oi etc.,esa.«r..❑ r. .�ti❑ <br /> O0 1S2 <br /> b <br /> Is this a New Baines tm.tioN not PtEVioU51y reoulated bd the E mow+o+tAL HPALTH DEPARTMENT? YEs ❑ No ❑ <br /> Is Cels an EL15Tma Business LoeATIoet but a Ncw Tyre or uLabed Business 7 m El No ❑ r <br /> 1 n/`L'i✓STS�7 L(�. C=! T�-j �/'e-�2 T" r Ilj <br /> Buswtss/FAaum/SNAr+E L,�T L 55� L- 1 r /f= <br /> 5&a*E# Busnlss pt&ONE � v <br /> ctry <br /> sT.Te ZIPy5 <br /> metres itDIfFFJ2t]VTNtomfid!/eyAddmss Attention:or Cam Of(0,PDW 9 <br /> Mailing <br /> la 7 � �--�txv�f2 �v t~ -# 3L5� �u�l ✓r �( Cf}— ��f 5 Z L - Cj-�rK� /� <br /> STATe Ten <br /> M.iiiing Address City <br /> ,t <br /> THIRD PARTY BILLING INFO: ComPieL�if Billing Party is differentfrmm Property Owner orFaCility Operator iden5fredabot- <br /> Attention:or Care Of (op6amaQ <br /> eusntess NAME <br /> PtiONtC <br /> Mailing Address <br /> STATE <br /> CSty <br /> for fees and Charges OWNER FACtuTv/BuswEss THIRD PARTY BILLING <br /> I,the undersigned ApplJcant,ca•6(y that I a_Ike 0-v,Opo j ,or'&dharircd Arent or mw ausiscu,ana!acko—iolee&hat ah PatMrFess. <br /> PENAL776;BnroAtrxrrn'rCx�ucfr3>aJ/orXOrAtLYGI�+�£S satodAnd wld+thu operalloa.eill ba titled ro me at rite address MeatIfiod spare as rYme <br /> mlrivrA--TV fro d&is ym, I mica o fify that all <br /> inlaraation prvvkled on this aPPritl6on 8 true and correct, sad that all rosulnttd scti"ities rvi11 be performed in accordance with sl!spplioble SAN JOAQuirl County Ordb-a Cairo andh.r <br /> Standards sad STATc■ad/or FLarxAL Laws sad RegnladoaL AA the andenip&ed owner,operator,or accut of the PrsPcrq located at the above facility/site addrem I hereby sulburize Ibe rvicwc or <br /> any and all rosdts and eovironmeotd assessment inrorm24o&s m SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEIAR Dort rs it i available and at the same rime it iF <br /> provWc-d m me or my-P---t-ti— PLEA"Pa3wr <br /> APPLICANT <br /> SIGfWTURl= - <br /> TrnJF c-ti,. ��—G �2� �� c-C JL ra►larocoPr arntm:r�, <br /> 03/22/2004 MON 16:34 [TX/RX NO 91341 003 <br />