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0 0 <br /> San Joaquin County Environmental Health Department <br /> GREEN FORM <br /> DATE MASTER FILE RECORD INFORMATION "MFRS/ <br /> cx.nm mcec cnx FHn xcc nxiv OWNER ID# IgE# UNIT IV <br /> OWNER FILE <br /> COMPLETE THE FOLLOWING PROPERTY OWNER INFORMATION; CHECRIF OWNER CURRENRYONFJIEW EHD <br /> PROPERTY OWNER NAME PHONE <br /> First ,rT MI Last 201437- &I-l" <br /> BDSINEgs NAME Clc 4 C/. k /� /Q L /1 $oc$EC/TwrID# <br /> �.jJyrLte Address( z Jl'�'L M1.7Cs��/FC DRLVnt's LL�LsE# <br /> STATE Zip <br /> OWNER Mailing Address <br /> Mailing Address City state ZIP <br /> TYx n.ALIO. <br /> CORPORATION❑ INDIWDUAL❑ PARTNERStain, Fm AGENCYOm <br /> FACILITY FILE <br /> FACn ID At CROs REFID# ACCOUNT ID# Irrv# <br /> R A <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 NE/W�TYPE of regulatedss <br /> rBusiness? /Ym E] Nc.° <br /> BUSINESS/FACrtnY/STTENAME t^Cl 5 , <br /> SIZE ADDRESS 701 A/ ///a-/,-L <br /> /v/ I-(e I^ SUITE# BUSINESS PHONE <br /> CITY t Y p&" C/%/ TSZ 0 STATE Zip <br /> BOARD OF SUPERVISOR DISTRICT LOGTION CODE KEYI KEYZ <br /> Mailing Address ifDIFFERENTfmm FadiityAddress Attention:or Care Of(optional) <br /> Mailing Address City STATE Zip <br /> sic CODE APA# COMMENT. <br /> THIRD PARTY BILLING INFO: Comp/ete if Billing Party is different from Property Owner or Facility Operator identified above. <br /> BUS[NESg NAME r � Attention:co-Care Of (quhrual) <br /> Mailing Address 32 2 f. PHONE26 '728-307, <br /> CRy /1/1-e <br /> r) S ��� Scan zip <br /> Ali=mul r4pruz K for fees and charges OWNER FACILrfy/BUSINESS THIRD PARTY BILLING <br /> R Avn TOWPI IAVPP.ACRxnWIFDGNIENT; L the undersigned Applicant,certify that 1 am the Owner,Operator,or AathRriwd Agent of this Business,and I acknowledge that a8 PERMIT Fees, <br /> P£N'ALUES,ENFORC£M£NTCHARG£5 and/Dr HOURLY CHARGES associated With this operation will be billed tome at the address identified above as the AP ImTAODRiec for this site. I also certify tbat <br /> all information provided on this application is true and carrece and that all regulated activities wan be performed in accordance with all applicable SAN JOAQUIN 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 fact]ity/sit¢ ddress,I hereby A thorn.the release m <br /> any and all results and environmental assessment information to SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon d is available and at the same e d is <br /> provided to me or my representative. q I� �. <br /> APPLICANT NAME PLEASE Pu� -5 SIGNATURE J'� , <br /> //�� ^ lit✓I c( K W4�o-el' ��T �3Z V� <br /> TIRE / C' / ' t DRNER'S LICENSE At <br /> (PHOTOCOPY REOUIRED) <br /> Approved By pate Accounting Office Processing Completed By Data <br /> 29-02-002 Apr1I 23.2003 <br />