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209-234-0538 Line 1 05"'01 P.M. 11-17-2008 212 <br /> ` San Joaquin County Environmental Health Dep ertment <br /> DATE MASTER FILE RECORD INFORMATION "MFR" GREEN FORM <br /> SHADED MEAS FOR EHD USE ONLY OWNERID# I <br /> `1 ` r ' � FC <br /> ASE# UNIT IV <br /> t OWNER FILE <br /> COMPLETETHEFOLLow1NGPROPERTY OWNER INFORMAT/ON• CHECK/F OWNER CURRRENTLYONFILEW1rH EHD <br /> PROPERTY OWNER NAME PHONE <br /> First M! Last <br /> BUSINEss NAME ` f O //-��Q� ` SoCSEC/TAXID# <br /> Owner Home Address ORNER'SLICENSE# <br /> City >LGet/ STATE ,4 ZIP <br /> Owner Melling Addrw <br /> Mailing Address City State Zip <br /> i <br /> TNPFnFOWMNFRSHI <br /> CORPORATION❑ INDIVIDUAL El PARTNERSHIP❑ FEDADENCY❑ O <br /> FACILITY FILE <br /> FACILITY I D# CROas REF I D# ACCOUNT I D# INv# <br /> COMPLETETHEFOLLowNG BUSINESS!FACILITY/SITE INFORMATION: <br /> Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPT.? YES ❑ No ❑ <br /> IS this an EXISTING Business LOCATION but a NEW TYPE of regulated Business? YES ❑ NO <br /> BUSINESSIFACIUTYISITE NAME L <br /> SITE AooREss 1 ! ,/J/tp ��l SUnE# BUSINESS <br /> PHONE <br /> CITY ( /� © //L / STATE ZIP <br /> BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEY1 KEY2 <br /> Mailing Address 1f01FFERENTfmn Fao111lyAOVress Attention:or Care Of(opLonal) <br /> Mailing Address City STATE ZIP <br /> SIC CODE APN# COMMENr: <br /> THIRD PARTY BILLING INFO: Complete ifBil ling Party is different from Property Owner orFacility Operator identified above. <br /> BueiNEssNAMEz / �f �ech/1,)� .-(f Attention:orCareOf(opUonalJ <br /> 4D/� ��/ c �1 <br /> Melling Address ,� r /e S'� ;�C�e l U/5fe PHONE <br /> CITY � c�—�7A/ V(/ __/J STATE/;4 ziPOC����� <br /> AccountrAavRess for fees/and charges OWNER FACILITY/BUSINESS HIRD BILL'ING <br /> BILLING AND COMPLIANCE ACKNOW'LEDGafENT: I,the undersigned Applicant,certify that I am the Owner,Operator,or Authorized Agent of this Business,and I acknowledge that all PERMIT FEt1, <br /> PENALTIES,ENFORCEMENT CHARGES and/or HOURL3'CHARGES associated with this operation will be billed to me at the address identified above as the ACCOIAW ADDRECS 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.IOAQUIN COLPTY 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,I hereby authorize the release of <br /> any and all results and environmental assessment information to SAN JOAQUIN COUNTY ENVIRONNIENTAL HEALTH DEPARTMENT as soon ayi is available and at the same time it is <br /> provided to me or my representative. (J// <br /> APPLICANT NAME 1150? aAd SIGNATURE I <br /> TITLE E 10 V t o� ,/In p;� a, e�1 G� i DRIVER'S LICENSE# <br /> lJl��� (Jr� J f[ �-1 f (P110TOCOPY REQUIRED) <br /> Approved By 1 Data Ao w-o on praoeeeing Completed By t> Drto 1 b <br />