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San Jo rjin County Environmental Health oartment <br /> GREEN FORM <br /> DATE -�S_p 2 MASTER FILE ^JR,E,CORD INFORMATION "MM" <br /> cweD�o e„�e�.Dn FHn,—n.,,. OWNER ID#Tq0 l/;J CASE# UNIT IV <br /> OWNER FILE <br /> COMPLETE THE FOLLOWING PROPERTY OWNER INFORMATION: CHECK IF OWNER CURRENTLYONFILEWITHEHD <br /> PROPERTY OWNER <br /> P' , l Q O I PHONE L[� <br /> NAME V� I \,ZPi� <br /> First MI last <br /> BUSINESS NAME1 C �7\I cC � SOC$E Ax ID# r 04--Z3 <br /> J •IF') J OU qq <br /> Owner Home Address -2(p f`J A DRIVER'S LICENSE# <br /> city � STATE /+ uP <br /> Owner Mailing Address 2 p t V ` e <br /> Mailing Address City Stabel _ Zip <br /> 9-C-2-0 6 <br /> T'DF nF nwNFRSHTP 1 <br /> r� tJ <br /> t� 4� ^ <br /> r�nODrlDerrrlN IY I TNnMnI lel FIY I I r' DeorucocHTD Fn AGFN (TFp I.r'''�I <br /> FACILITY ID# :n 0 ���p CROSS REF ID# AccouNr ID# ��� 9 Inv# <br /> COMPLETE THEFOLLOWING BUSINESS I FACILITY I SITE INFORMATrON,' <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 lJd No ❑ <br /> BUSINESS/FACILITY/SITE NAME <br /> ?ev\.`s <br /> SITE ADDRESS SUITE# BUSINESS PHONE <br /> -Tiptc. � 2. )4�l-c — I I I l <br /> CITY CIA S 20 (p <br /> BOARD OF SUPERVISOR DISTRICT I LOCATION CODE KEY1 I KEY2 <br /> Mailing Address ifDIFFERENThom Facility Address Attention:or Care Of(optional) <br /> Mailing Address City STATE Zip <br /> SIC CODE APN# COMMENT: <br /> THIRD PARTY BILLING INFO: Complete if Billing Party is different from Property Owner or Facility Operator identified above. <br /> BUSINESS NAME n f7 �`5 T� Attention:orCareal) <br /> OSGO+4r <br /> Mailing Address lob ` . I } J PHONE Cs to 23? -3 god <br /> Cm e W 641 STATE ZIP I L+go L <br /> p -I <br /> d��nrrW 40DRF S for fees and charges OWNER FACILITY/ROSINEG TSS HIRD PARTY BILLIN <br /> Rn.r.INc AND CONIn.IANrE ArtiNrnvI.FDGNfENT: 1,the undersigned Applicant,certify that 1 am the Owner,Operator,or Authorized Agent of this Business,and 1 acknowledge that all PERAUT PEE. <br /> PEN-ILTIES,ENFORCEVENTCHARCES and/or 1101 RLYCHARGES associated with this operation Hill be bill"tomtaddress identified above as the ArCOV TADDRFS4 for this site. I also certify that a <br /> information provided on this application is true and correct;and that all reg ted a T'1 accordance with all applicable SAN JOAQUIN COUNTY Ordinance Codes and/c <br /> Standards and STATE and/or FEDERAL Laws and Regulations. As the undersi d Te ro erty located at the above faciliq'/site address,1 hereby authorize the release <br /> am'and all results and environmental assessment information to SAN JOAQ Y L HEALTH DEPARTMENT as soon as it is available and at the same rime it <br /> provided to me or my representative. <br /> 1 PLEASE PRINT <br /> APPLICANT NAME 4-6AyOSCOr SIGNATURE <br /> TITLE ((PHOTOCOPY REQUIIR D) F2-5 5 3�4- l 3 I <br /> Approved By Date Accounting Office Processing Completed By Date B <br /> 9 3o/r-z- <br />