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Sit; <br /> San Joaquin County Environmental Health Department <br /> GREEN FORM <br /> DATE 5 -27-2-00 MASTER FILE RECORD INFORMATION `nMFRrr `, <br /> sn ne song OWNER ID# !{�.I Db0 'l-� CASE# . IT I7005 11 IN - 1 PH v <br /> (�L�J OWNER FILE <br /> COMPLETE THE FOLLOWING PROPERTY OWNER INFORMATION; S A NF.`iA7€14;�''Uf7'FXPw nLl wrrN EHD 0 <br /> r e cr <br /> PROPERTY OWNER NMtE G! T o iS77�C.1�. /U 1N{f�1�T 0�/NUA11U i; E -(3-71/0 <br /> /'� First MI Last <br /> AM <br /> BUSINESS NEDT o TLY,L'rOxJ - rE?EfarcvJlF�,ttJ45TE,k14t'PZ�oN AUur SOC SEC/TAX ID# 91-61000X3(,, <br /> Owner Home Address Ua DRMRSLICEIll <br /> city Sroe-,e.TOA) U STATE/ a1 Zra QS <br /> Owner Millais Address 75&oI Ip,u y D a4 v L <br /> Mailing Address City 5 -rO G�-rO1� State /r AIS IP 1t,2106rnPrsPOunaroaurP C.- <br /> CORPQRATION❑ INDMWAL❑ PMTNERSHv❑ FED AGENCY El <br /> FACILITY FILE p <br /> FACILITY ID# ' / �Y I CROSS REE ID# ACCOUNT ID# im'# <br /> COAMEZE THEFOLL014TNG BUSINESS if FACILITY SITE lNrogmviirom <br /> IS this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? l YES ❑ NO <br /> IS this an EXISTING BusineSss LOCATION but a NEW TYPE Of regulated BusinfSsY YES ❑ Nofir <br /> BUSINESS/FAmJTY/SDENAME C.JT ©F `STOc-IL7t'�1 'r�Efato/vI�LIA�145rEUTAT �oAlr1ZL_ i�UUF <br /> STIE ADDRE$$ 2 J�w1 I I.A v I `ICY(�L sDIIE# BUSINESS <br /> cN AJA .J.J IS 9 <br /> CITY 'jTOC-1LTOA� sTAre A ZW 95ZO6 <br /> BOMD OFSUPERVLSOR DISIRICf LOCKTIONCODE KEY1 KEY2 <br /> Mailing Address IfDIFFERENTfrorn Fad/Ry Address Attention:or Care Of(oluMmp <br /> Mailing Address City STATE ZIP <br /> SIC CODE APN# COMMENry <br /> TRIM PARTY BILUNO INFO. Completed Billing Party is different from Property Owner or Facility Operator identified above. <br /> Blmfffss NAME Attention:scars W (npb'onsQ <br /> vOe/Z E4R77} Tt�rtneuLCXXaIES G. f i'l--7, <br /> Mailing Address ISS Fi2A.v '!. 1.f9E:sr G,ecl.c �L(/TE 1 PHONE �Z1J''I ��OSr� <br /> Cm CTO GK T OfJ STATE(-- 4 Z]P 1 <br /> AC,22UATA=.Ess for fees and charges OWNER FACILITY/BUSINESS /+ 5 THIRD PARTY BILLING <br /> 1,the undersigned Applicant,certify that 1 am the Owner,Operator,or Authorized Agent of this Business,and 1 acknowledge that til PERMITF££S, <br /> PENACDES,ENFORCEMENTC/LSRGE and/or HOGRLYC//AHGE ....elated with this operation will be billed to me at the address identified above as the ACCOLINTAUnRGer for this site. 1 Asa certify that <br /> an Information provided on this application is true and correct;and that all regulated activities will be performed in accordance with all applicable SAN JOAQUN Coum Ordinance Codes and/or <br /> Shndardr and STwrE anNor FEOERAI.Laws and Regulation.. As the undersigned owner,operator,or agent of the property located at the above facifiry/site address,l hereby authority the release of <br /> any and all results and environmental assessment information to SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT,.}noon as it is available d at the same time it Is <br /> provided to me or my representative. P recE PRIM /// 1 17 <br /> APPLICANT NAME �siSE,f SIGNATUREy <br /> TITLE T,-+F-r /' E�LO�I DRIVER'.LICENSE# - <br /> S 1.� S f (PHOTOCOPY REW,RED, _ <br /> APfwoeed BY Doh A000untlrsg UfRcs Prviceoing Completed BY Dare p <br /> 29-02-002 April 25,2003 <br />