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209-234-0538 Line 0` Ot P.m 11_17_?O08 7 <br /> San Joaquin County Environmental Health Department <br /> DATE �' FASTER FILE RECORD INFORMATION "MFR's GREEN FORM <br /> SHADEDMEAS FOR EHD UBEONLY OWNERID# CASE# UNIT IV <br /> OWNER FILE <br /> COMPLETETHEFOLLOW/NG PROPERTY OWNER INFORMATION: CHEcKIF OWNER CuRReyrt YON FILE wim EHD <br /> PROPERTY OWNER NAME PHONE Ld 01 <br /> First Ml !asf <br /> BusINEnNAME !' O ^ ��C �Q� SOCSECITAXID# <br /> Owner nUril6 Address `Q1. �d'�` ORNER'DLICENSE# <br /> City C C ,I ccLL//l STATE ,` ZIP <J5141? <br /> Owner Mailing Addre <br /> Mailing Address City State yip <br /> CORPORATION_i INnIV!nVALQ FED AGENCY <br /> FACILITY FILE <br /> CI FACILITY lD# CROSS REF ID# - - .1-ACCOUNT ID# - INV -- .. <br /> COMPLETETHEFOLLOW/NG 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 LOCAATION but a/N�EWTYPE of regulated Business? YES ❑ No <br /> BusiNEBSIFAciuTY1SiTENAME <br /> S(TEADDREss 8urE# BUSINEWPHONE i <br /> CITY �I�c��` � STATE--'A- ZJP <br /> BOARD OF SUPERVIaOR DISTRICT LOCATKIN CODEKe^I KEr2. <br /> Mailing Address ifDIFFEREMTfromFacilityAddress Attention:or Care Of(optional) <br /> Mailing Address City STATE ZIP <br /> SIC CODE APN# Commw-' <br /> THIRD PARTY BILLING INFO: Complete ifBilling Party is(c fferent from Property Owner OrFac i!ity Operator identified above. <br /> Bust NEss NAME Cin C/O� vA 7�?clO Attention:or Care Of(optlonal) <br /> Mailing Address I L f�f� t n/e� i�/� ��/c�e PHONE — <br /> CITY j/�-�N �^ Wes STATE zIP�JCCy�"�O� <br /> AccmwrADO/PESS for fees and charges OWNER FACILITY/BUSINESSBIRD PARTY BILLING <br /> BILLING AND COb1PLIANCE ACKNOWLEDCbtENT. I,the undersigned Applicant,certify that I am the Avner,Operator,or Authorized Agent of this Business,and I acknowledge that all PF.R'4.Ir FEa', <br /> PENALriEs,ENFoRCEbIENTCAARGES and/or HOURLY CHARGES associated with this operation will be billed tonic at the address identified above as the ACCOMYTAooxEir 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 JOAQUtN COV\Ty 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 ENVIRONMENTAL HEALTH DEPARTMENT as soon a ' is available and at the same time it is <br /> provided to me or my representative. <br /> APPLICANT NAME )g5on A 11le-' Y! �/� SIGNATURE <br /> TITLE J- �t D �l f 1 DRIVER'S LICENSE# s1-71 <br /> (PHOTOCOPY REQUIRED) <br /> Approved BY Data Acowtttlnp o1Moa Procwsinp Compktad By Date —� <br />