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rerg <br /> Joaquin Count Environmental Health Department <br /> San Joaq Y GREEN FORM <br /> "'E "MFR" <br /> MASTER FILE RECORD INFORMATION <br /> cwencn sorac mR FHO_u_gr.ON1 V OWNER ID# CASE# UNIT IV <br /> bl>�DD�SSS 3 <br /> OWNER FILE <br /> CHECRIF OWNER CVRRENTL YON FILE WITH EHD ❑ <br /> COMPLETE 7HEFOLLOWNGPROPERTY <br /> �t� <br /> OWNER INFORMATION; !� /y (� <br /> PROPERTY OWNER NAME •• PHONEi, C 6 <br /> First Last <br /> BUSINESENME <br /> SOC SEC i TA)t ID# <br /> Owner Nome Address r DRIVER'S LICENSE# <br /> City A C, A �J{/ Y V ti sv Y STATE A ZIP III } <br /> I v <br /> f Owner Mailing Address , <br /> State :.Zip <br /> Mailing Address.City <br /> TURF AF A WNFRSXIP_ <br /> CORPORATION❑ INDIVIDUAL❑ PARTNERSHIP❑ FED AGENCY❑ OTHER❑ <br /> FACILITY FILE <br /> } ACCOUNT ID# <br /> FAaLmr ID# 1 CROSS REF ID# <br /> CoffPTETIFTREEMLOPITW BUSINESS I FACIL11Y I SITE LMEQRAfA7T0N,' 11 T\l] L l Ip <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 /> BDsINEss/FACILITY/SITE NAME !�-. O� a 'Tf C4 i5 I' <br /> GQ L R �y SUITE# 6uslNEss PHONE <br /> $ITE ADDRESS 1 ��e /�re 1 <br /> CITY' s <br /> CSTATE CA Zm sa <br /> . <br /> # KEY2 <br /> BOARD OF SUPERVISOR DYSTRICY i LOCATION CODE -KErl <br /> __]if <br /> Mailing Add ifDIFFEREIVTf-am Fat:rlityAdd Attention:or Care Of(optional) <br /> Mailing Address Cityrx 4 l`rrj_ , r /rCk"' O S � � STATE f ZIP <br /> SIC APN#O l o V U V{ COh1MENT:w _ .•, �. -- - ,.. .r�"`r"�" .,..-.+.,moi <br /> ..-y. <br /> THIRD PARTY BILLING INFO: Completed Billing Party &different fmm Property Owner or Facility Operator identified above. <br /> BUSINESS NAME Attention:or Care Of (optional) <br /> Mailing Address '39W <br /> 9(1 C lin w Ro,L <br /> PHDNE _ I[}� / j <br /> CITY 5CLkI aJI'KUy1F V �- STATE CA ZIP (—f Ly 5(ry 1 /an !ftf'eCC0' urennRccc for fees and charges OWNER FACILITYiBUSINESS THIRD PARTY BILLIRll.I.IN(:ANTI C!]MPt.IwNf FACK N(1V 3.FnCM1'N'1'; I,IIIb•Illider5i(�'ned Applicant,Cerlif}'th:lf I:Iln the t)rwter,()f)efGfur,Ur�l utlruriz vt/I�;eltf n(tllls Business,and l aCknOWIC(IgC that NII PERhfl7PENAL77F..S,ENFoRCEMENTCl/AR4E.S andlornPDffi.VCIfARGES associated With this Operation Will be pilled to me at the address identilI10 above as theL{CCYIilm I DfiE.S.S fur this Site, 1;1190 Certiall information provided on this application is tree and correct;and that all regulated activities swill he perl'orured in accurdance with all applien[Ile SAN.10A0111N COUNTY Ordinance Codes <br /> Standards and STATE and/or FEDERAL.Laws and Regulations. As the undersigned mvner,uperatur,or agent of the properiy heated al Ilse above lhcilitylsite address,I hereby AuthorIZC the rel <br /> any and all results and environmental assessment information to SAN JOAQUIN COUNT)'ENVIRONAIVN'rP.L.I1LALTH.DEPARTMENT:s soon as it is available and at the same <br /> provided to me or my represents've. <br /> APPLICANT NAME r PLEASE PRINT <br /> l SIGNATURE <br /> TITLE n \ DRIVER'S LICENSE# <br /> He c4ae�r <br /> (PHOTOCOPY REQUIRED <br /> Approved By Date_ I Accounting Office Processing Completed By �'�r Date 1 <br /> 29-02-002 April 25,2003 <br /> 6 _� <br />