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_� r-• San J00r! County Environmental Health Oartment <br /> GREEN FORM <br /> June, $ ?Z0 MASTER FILE RECORD INFORMATION A'kMFRff <br /> cenuv OWNER ID# Rig 6f)9abAS <br /> CASE <br /> UNIT IV <br /> OWNER FILE <br /> CHEarLF OWNER CutrRE,mroHFnEfvrrH EHD ❑ <br /> COMPLETE THEFOLLOWING PROPERTY OWNER INFORMATION; <br /> PROPERWOWNERNAME -j AA k-e n SNE 90q- y7 - I a <br /> lJ� First MI Last <br /> BUSINESS NAME S1-�+-`Jn e/ ��"� SOc SEC/TAX ID# N/A. <br /> Owner Home Address 1 1 lDRDIEWS LICENSE# 4N N/A <br /> city A <br /> STATE ZIP 1 <br /> Owner Mailing Address 1 oa y <br /> Mailing Address City r5l�V , , StateA 2iP l76a0-7 <br /> T ",,FnWNFRsHm `J, ' L(%7l' �1 <br /> CORPm1ATION❑ INDMDUAL❑ PARTNERSHIP C1 FEDAGENCY❑ OTHER❑ <br /> CAO V M6, r 0(6) `70 FACILITY FILEIN <br /> FAauTrID# CROSSREFID# AccouNrID#g # 75 <br /> ComPLETE THE LL RMA N• <br /> Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ No 93 <br /> Is this an E7OSRNG Business LOCATION but a NEW TYPE of regulated Business? YES ❑ NNo 1E /�`�'��Y1{�-'' <br /> BUSINEss/FAQIITY/SnENAME�•,lr+�YhrSJY/.f� /� /� mMP S .L\0 CCI �t1�.CC CA 1` r <br /> SITE ADDRESS 5J f/`0 f (�'L.yTI t c �11 I G Avp—()llllUll`�� SUnE# BUSINESS PHONE �-// <br /> CITY r,.., ,'/lam:fK�f L.l� STATE/'/� Zip�lJ� I <br /> BOARD OF SumvisvisoR.D /ISTRI,. a LOCATION CODE �,1 Z C.rT <br /> Mailing Address ifDIFFERENTOofn FadlityAddrEss Attention:or Care Of(opdonaV <br /> �V m R� ?©. ao�c ICCp9 .n C.G4L <br /> Mailing Address City Cr�tr, LUIS �sb lS'7C) STATE CA!1 ZIPC1-9j„4C)(o <br /> SIC CODE ��llf�4Y �'APN# COMMENT: / <br /> THIRD PARTY BILLING INFO; Complete if Billing Party is different from Property Owner or Facility Operator identified above. <br /> BUSINESS NAMEAttention:orCare Of (optional) <br /> Mailing Address j0Lgj1 01C) ?10,Cervi Ile • `t.�N/� S�+, e 0\(:) <br /> \G SNE C`7//_- �' <br /> cm ` C.t'0�'(' 'cFb �i�� ��1757 STATE f(/ gJPf.�958j' <br /> Accaunrr ngaum for fees and charges OWNER FACILITY/BUSINESS H D PARTY BILLI <br /> R r ANrr nrRNOW encns rvT: 1,the undersigned Applicant,certify that 1 am the Owner,Operator,or Authorized Agent of this Business,a ae ow edge that all PERMIT FEES, <br /> PENALTIES,ENFORCEMENTCHARGES and/or HOURLY CHARGES associated with this operation will he billed tome at the address identified above as the ArrOHNTADDRas for this site. I also certify that all <br /> information provided on this application is true and correct:and that all regulated activities will 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 facility/site address,1 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 is <br /> provided to me my representative. <br /> N SIGNATURE <br /> uL41UZ-6UC.r%r/ <br /> APPLICANT NAME �ly /jY�q�l�Q PLEASE PRINT <br /> J <br /> TITLE n r DRIVER'S LICENSE At <br /> fr� ��`�✓✓ +- �ii/��� fPHOTOCOPY REQUIRED) <br /> App etl ByI Data Accounlin9 Office Processing Completed BY Dafe <br /> 29-02-002 April 25,2003 , <br />