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San Joaquin County Environmental Health Department <br /> GREEN FORM <br /> DATE .5 -27—Z�oS MASTER FILE RECORD INFORMATION "MFR" <br /> OWNER CASE# U IT IV <br /> PM 2 <br /> OWNER FILE <br /> F�x�g p Lily in Ula ER yFrIl�y��� <br /> MPLE)F THEFOLLOWINGPROPERTY OWNER INFORMATION; "azLf&E r END El <br /> $Q <br /> e <br /> PROPERTY OWNER NAME G! T .O{ ,570GX. A rWWT6�,MUAAU IN10� E -87Y0 <br /> Firs( MI Last <br /> B mN sNAMEOT O Tc-KTOIj - �f�7lONRC-IkA5rr-w* w COR) ACJLF Soc S[t/TAx ID# <br /> Owner Home Address Z 5 OO /vA t) l//,iz i U� hliaLicenseDa 'sLicense# <br /> Ill STOe-g TO)lJ STATE/r/t ZIP <br /> Owner Mailing Address Z5&0 IUAYJ IJ��e: LST /✓ CIIO <br /> Mailing Address CRY 5 TOC.JGTO State (fA Zip -9.5 z66 <br /> coRPQfUTIo i❑ INDMDUAL❑ PARTNERSHIP❑ FED AGENCY❑ owEx� <br /> FACILITY FILE <br /> FACILtTYIDat CROSS REF ID# ACCOUNT ID# INV# <br /> Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTM ENP YES ❑ NO <br /> Is this an E%MSTING Business LOCATION but a NEW TYPE Of regulated Business? yes ❑ NO <br /> BumeFss/FACDIIY/$IR NAME GT OF STOCK•TQAj 'RECn IO/UA(—VJAS-rr_ AT �O.UT�C_ ALILJT <br /> STtEADDRE552.5� / l)4L) t\ lL) f wrrE# 8ti"V P E� <br /> cry To c�TOIIJ �J L srATEc� 95zo 6 <br /> BDMDUFwPERV15OA OLSnaSf LOCATION Cone KEYl. IOY2 . <br /> Mailing Address/fDIFPERENr/Tum,FadRtivAddkes; Attention:or Care Of(opbona/) <br /> Mailing Address City STATE ZIP <br /> SIC CODE APN# commeNt: <br /> THIIIG PARTY BILLING INFO: Complete if Billing Party is different from Property Owner or Facility Operator identified above. <br /> Business NAME Attention:arcane Of (optlana/) <br /> vpo)L E�APL7W /t-J-bT <br /> Mating Adtlress /88 FFZ AJAU - W&ST (..JRCJ & 4417-& 1 <br /> CPNora:�CZ�09 �'OSIcY <br /> m G�-Tr7GK T O/J STATEC Jr zIP /9L'^� <br /> ^^^'« <br /> AQMUATwfor fees and charges OWNER FACILITY/BUSINESS THIRD PARTY_BILLING <br /> 1,the undersigned Applicant,certify that 1 am the Owner,Operamq m Amhori¢ed Agene of this Business,and 1 ackumviedge that all PExwrFecs, <br /> P£ na,EYFORCEMFMCUMCHT anter HOURLYCn Wa associated with this operation will be biUcd tome at the address identified above as the 4.1ZIA.U.-for this site I also certify that <br /> all Information provided on this application is true and correct and that all regulated activitim will be performed In accordance with all applicable SAN JOAQM COnTY Ordinance Codes amber <br /> Standards and STATE and/or FEDERAL Laws and Regulations. As the undersigned owner,operator,or agent of the property located at the above facBuy/site address,l hereby mMorir<the release of <br /> any and an results and environmental assessment Information to SAN JOAQUIN COUNTY EMIRONMENTAL HEALTH DEPARTMENT,y anon v it i�avmlblc atthe same time it la <br /> provided to me or my representative. / /r/1//� <br /> APPLICANT NAME /r�SEY ✓ �Pawl SIGNATURE y <br /> � <br /> TITLE L_ L DRrVER'S LICENSE# <br /> S'TkF9 G EOLOGr7 S J (PHO OCOPYREWIRED) <br /> Approved By Date Aaounung Mm Processing Competed By Date <br /> 29-02-002 April 25,2003 <br />