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San Joaquin County Environmental Health Department <br /> DATE f 11 Ip} MASTER FILE RECORD INFORMATION "MFR" GREEN FORM <br /> C"AnFriaimAivionewn OWNER ID# CASE# UNIT IV <br /> �,EOo 1 So•1 <br /> OWNER FILE <br /> CONPLE7F 7fffFoLLOWING PROPERTY OWNER INFORMATION: CN£Ess OWNER CNRR£NrzroNETEE WnH EMD <br /> PROPERTY OWNER NAME PHONE <br /> First MI Last <br /> BUSINESS NWE J 1—t 1. lh •• 1 - 1�a e-, �� SOCSK/TAXID# <br /> Owner Home Address 't0 i1t--1UY� V�/11.1 FN---A DRWER'S1]CEIg;C <br /> city STATE 211" <br /> Owner Mailing Address d ` r 1110. •'Dr• <br /> Mailing Achress City vV �. Stare Get- aP <br /> Tvx rx nw �O� <br /> Co1PORAT[oN❑ Ira)mnmu L❑ pARTNERADP� FED AGENCY❑ OTHER❑ <br /> FACILITY FILE <br /> FAGLIIY ID# CROSS REF ID# ACCOUNTID As INV# <br /> 6u) j 6\0 2 b ko 4b 322-- <br /> TNEFOLLOWING BUSINESS I FACILITY / SITE INFoRmA77oN., <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 /> BUSIIE55/FACOIiY/SITE NAME �_.� ��/��rt C ri.��� <br /> SITE ADDRESS S-113 G . Moi-7,� Slit- st # BSE PHONE <br /> cm S o ck—+T-� STATE TT 1\ 78 15215 <br /> BOARDOFSUPERYISORDISTRAT J LOCATEN CODE KEY1 KE'e2 <br /> Mailing Address IfDIFFERENTYrpm FacilifyAddress Attention:or Care Of(Optional) <br /> Mailing Address City STATE ZIP <br /> sic CODE APN# COMMENT: <br /> THIRD PANTY BILLING INFO. Comp/e(e if Billing Party is differentfrom Property Owner or Facility Operator identified above. <br /> BUSINESS NAME .S �` D, n I JKC Attention:octane Of (optrmraq <br /> A 20. E� <br /> Mailing Address ciOZINI .S �j w PHONE p3.4-� <br /> cm STATE l/Iv zw IS2' ITR <br /> �'^^•r"m en^^tea'•'for fees and charges OWNER FACILITY/BUSINESS THIRD PARTY BILLING <br /> RIRrNP awn r'nxmnsNre arxwnwrsnrnsxwr: L the undersigned Applicant,certify that I am the Owner,Operator,or Authorized Agent of this Business,and I acknowledge that all PE1tM1II7F£ES, <br /> PENALTT£S,ENFORC'F.Af CNdM and/or nOnRLYCRARGES associated with this operation will be billed tome at the address identified above as the 4=r TADDRFcc 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 JOAQM 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 facility/site address,l 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(be same time it is <br /> provided to me or my represen^taAti^v1e.1 p_ �Y <br /> APPLICANT NAME A)0, -1 IAGr� PI sa6 PRnrr SIGNATURE , <br /> TITLE !�� .1 _.L SU�/�I �•.L DRIVER'S LICENSE <br /> '#'' 1 jSo 8 3S cS 3 <br /> f W� 'C� 1 (PHOTOCZIPT IREDI <br /> Approved By l Jtoh.. DV_7-//t%; Accounting Office processing Comply BY Date 3b 71=1 <br /> 29-02-002 April 25,2003 <br />