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Sep- 25. 2007 3: 59PM Advanced Geo Environmental No- 9849 P. 2/2 <br /> San Awn County Environmental Health Drr, trtment <br /> GREEN FORM <br /> DATE MASTER FILE RECORD INFORMATION "MFR" <br /> CNef]Fn AppAG RFNnligFoNIV OWNERID9 7 cAse# UNIT IV <br /> OWNER FILE <br /> MPLEMTHEFOLLOWINGPll P INFORMATION' CHrcArF OWNER Cur�eRrvnroNrnewrnv EHD <br /> PROPERTY OWNERNAMLI P}+oNE <br /> First roil Last <br /> RUSINM NAME D �'az-a PG2- Soc SEC/TAx ID# <br /> Owner Home Address Dstrim%i LICENSE# <br /> City STATE 21P <br /> owner Hailing Address <br /> [MBIiIngAddress City StY Yt (�Y1C SC4 srue (2 LP qq!314 <br /> MMFn AWNmewp <br /> CORPORATION❑ INDIVIDUAL❑ PARTNERSMP❑ FED AGENCY❑ onum 0 <br /> FACILITY FILE <br /> FACASTY ID# L 6s REP ID# ACCOUNT ID 4 INV# <br /> F� <br /> Is this a NEW Business LOCATION not Previously regulabed by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ No <br /> Is this an EXESTING BWness LOCATION but a NEW TYPE or regutatad Buslnew7 YEs GJ— No ❑ ~ <br /> 6VSV95S/F-AQL]TY/SITENAML _De,tl tT U.�prT <br /> SITE ADDR65 SurrE It RUSBAM PHONL <br /> CITY LMIJU� 2C'O. STATE CIA 20p q 5 33(P <br /> BOARn OF SUPemrs it DI+,CT LocATION CwE Kiri KFY2 <br /> Malling Address/fDD+'W?EN7'hvm FactftAld rens Attention:or Care Of(apdotraf) <br /> Mailing Address City STATE ZIP <br /> SICCOpE APN 3t COMMENT: 1 <br /> THIRD PARTY 13ILLINO INFO; COmp/e1e/f Billing Party isd/fTerent from Property Owner orFadlity Operator identifiad above, IUB—1 <br /> Rusmss NAME Ateentlon:arCare Of (gvtVona/) <br /> I <br /> Mailing Add au) R 7779- - `L_ <br /> CSATE <br /> kW -Inn 0A <br /> 41=11FA nlnnoacr for fees and charges OWNRR FAGLITyiBusINESS THRD PARTY BILLING <br /> Rn.i.rNr.ANn roMPtlAN(T Actciow Ens Nr; 1,the undersiptd Applicant,certify[hat I um dw Ovmsr,Opwator,or ArrdwrfW Aged of tbia auAness,and I acknowledge that all PIRwrrm, <br /> PEYALnFS,EMACffiffiNT 0Z4ftCW and/or HOURLYCNARoltt smodated with this operation will be billed to me e t the address identified above As the A CMU TAnnRAT for this site, I also certify that <br /> all information provided on this application is tree and corrom and that all regulated activities will be performed in accordance-ith all applicabk SAN JoAQLAN COUNTY Ordinance Codes and/or <br /> Standards sad STATS and/or FEDEPAIL Lswi and RegWadons.As the underdped owner,operator,or seen of the property located at the above fadUty/site address.I bereby autho the rdease of <br /> any and all results and coviroetnental m9mment information to SAN JOAQUIN COUNTY ENVIYZOIVNM TAL HEALTH DEP hfENT n is is available and et ae me time it i9 <br /> prodded to me or my represcotativa <br /> PLEASE pansT <br /> APPLICANT NAME MGNATU <br /> ki <br /> TITLE ORiyER'S LICENSE# G J Q <br /> U 1C e P�I C�P r�� (t HOTOCOPr REOUBU D1 TtTI d !� <br /> Ap —W By Dal♦ Aocoundfm Office Pmeessln0 comptefee 6/ Da" <br /> 29-02-002 April 25,2003 <br />