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San quin County Environmental Healthepartment <br /> GREEN FORM <br /> DATE 11� X05 MASTER FILE RECORD INFORMATION xAMFRrt <br /> �- res,FNn ne,CAA OWNERID# Ilt/5'9 CASE# UNIT IV <br /> OWNER FILE <br /> CHEI](IF OWNER CURRENTLYONFFLEWIrH EHD ❑ <br /> COMPLE7FTHEFoclolvzNGPROPERTY OWNER INFORMATION; <br /> PROPERWONINERNAME �1/'KR-S-1- q sA� PHONE e.�-�3- 089 1 <br /> First MI Last <br /> Bumess NAME ?f,`J(VI-C— t'J -r.- f1 ; SoCSEc/TAxID# <br /> DRWER'S LIcENSEAt <br /> Owner Home Address <br /> City STATE ZIP <br /> owner Mailing Address `q L+ ti�j- COA Ds'N j(,, S� - / S)-e - L ter( <br /> Mailing Address City State C� Zip 95Z <br /> TVPFeAFnwNFRezjm <br /> CORPORATION❑ InomowL�. PARTNt'AST�❑ FgDAG Nt7rE1 _OTHER❑ <br /> FACILITY FILE <br /> FACfEID# , I C'QI Caoss REFIII' <br /> ACCOUNT ID# ��.. 1 Q Dfy# <br /> E7F O yy ` a A7 n • U <br /> Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? yes �] NI <br /> Is this an E)GSIING Business LOCATION but a NEw TYPE of regulated Business? yes ❑ No <br /> Bumm/Fanny/SITE NAMEN^ �` 1 <br /> SITE AIHIRFss 5-05,5 F-• 'r`(M✓\ c�T' SIfITE# BUSXI PHONE <br /> STATE Cj\ ZIP9SZ1S <br /> COY S.�'D c.�{-uv� <br /> BOARD OF SUPFAV15lMi DIsrFu LOCATrON CODE KEyl KEy2 <br /> Mailing Addnss ifDIFFERE/Vrfrom F"ItyAtttiLess Attention:or Care Of(optional) <br /> 014-4 N, CW%-Ptrvo\c, Si I Ste" G �v✓ es+ \/asA� <br /> Mailing Address City 54b-C&+n-\ STATE C�I ZIP <br /> SIC CODE APN# COMMENT! <br /> THIRD PARTY BILLING INFO; Complete if Billing Party is differentfrom Property Owner or Facility Operator idenryfied above. <br /> BUSINESS NAME yy-SSOG Attention:or Care Of (optional) <br /> N61 o. �a� t �101i liza«a <br /> Mailing Address "1 0 Z 1 S �'yI u� I PHONE 310 <br /> CITY to to J SraTE CA ZIP C(5 Zq L7 <br /> AQ=UAg Anne EFS for fees and charges OWNER FACILITY/BUSINESS PARTY BILLING <br /> CILITY/BUSINESS THIRD <br /> R " C' 11NrT A....WI EUL W ENT: 1,the nndeeslgned Applicant,certify that I am the Owner,Operator,or Authorized Agent of this Business,and I Acknowledge that all PERMIT FEES, <br /> PENALTIES,ENFORCEAlEw CHMG£S and/or MOORLYCHMGM associated with this operation will be billed to me At the address idenfified above u the ACCOONTADnxR,es for this site- 1 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 JOAQUIN COl1NiY 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 as it is available and at the same done it is <br /> provided to we or my representative. (� PLEASE PROff <br /> APPLICANT NAME ��;� � PL,LC, SIGNATURE J <br /> �NJ�1J1rDNf�'1/�T ry[ SfLe DRIVER'SLICENSE# <br /> TITLE �jSO g'�s <br /> C..t �r (PHOTOCOPY CENSED) v / <br /> Appmvetl By Date Accounting Office Processing completed By Date / <br /> 29-02-002 April 25,2003 <br />