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San Joan County Environmental Health D4rrtment <br /> DATE 1 �I o� MASTER FILE RECORD INFORMATION "MFR" GREEN FORM <br /> SHADED AREAS FOR END USE ONLY OWNERID# CAGE# UNIT IV <br /> OWbDD2g�1 <br /> OWNER FILE <br /> COMPLETETHEFOLLOWINGPROPERTY OWNER INFORMAT/ON.' CHecKIF OWNER CURRENTLYONFILEnoTH EHD ❑ <br /> PROPERT'eOWNERNmE PHONE gay <br /> First M, Last <br /> SUSINEss NAME 06 PO SOC SEC/Tm ID# <br /> Owner Home Address DRIVER'S LICENSE# <br /> City ar I e < STATE ('+3 zip 9 S 33 <br /> OWOar Mating Addrw 1 200 1 5 0 vfG H % 0 w k 5 ry <br /> Mailing Address Chitty/ L A State A 71P 95-336 <br /> CORPORATIONI)A INDIVIDUAL❑ PARTNERSHIP❑ FEOAGENCY❑ OTHER[I <br /> FACILITY FILE <br /> FACILMID# OD 1 CROBsREF ID# ACCOUNTID# �Rob 3`W INV# 1-7Sg4.S� <br /> COMPLETETHEFOLLoww BUSINESS/FACILITY I SITE INFORMATION: O T <br /> Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPT.? YES ❑ NO <br /> Is this an EXISTING Business LOCATION but a NEW TYPE of regulated Business? YES ❑ No <br /> BUSINEss/FACIL"ISITE NAME 1'1S <br /> < <br /> SRE ADDRESS S<. 1 9SURE# BUSINESS PHONE <br /> IZfoU I v 14 Ili IsWw `I \ <br /> CITY M ti n Ft c y STATE L A ZIP <br /> N <br /> \ <br /> BOARD OF SUPERVISOR DIeTRICT LOCATIONCOOE KEel KEY2 60 <br /> Melling Address HO/FFERENTJ5v nFact/1tyAddress Attention:or Care Of(opLona/J <br /> V J <br /> Mailing Address City STATE ZIP <br /> SIC COOS APN# COMMENT: (� <br /> THIRD PARTY BILLING INFO. Complete ifBilling Party is different from Property Owner or Facility Operator identiTed above. <br /> BUSINESS NAME Attention:orCare Of (Optional) <br /> Kitt, C � d e i ���qsyya <br /> 1 / ))��q <br /> Melling Address PHONE <br /> 2UO va —�/! <br /> w H (3 L titi n <br /> OnY S t o L Ic i o v. STATE GW zip <br /> ACCOUNTAOOREss for fees and charges OWNER FACILITY/BUSINESS THIRD PARTY BILLING <br /> BILLING AND COMPLIANCE ACKNOWLEDGMENT: 1,the undersigned Applicant,certify that I am the Owner,Operator,or Authorized Agent of this Business,and I acknowledge that all PERUrT FEES, <br /> PENt U=,ENFORCEVEHr Ci Gizv and/or HOLRLYCiz utu s associated with this operation will be billed to me at the address identified above as the Accofmv'ADDREfs for this site. I also certify that <br /> dl 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 /> itandards and STATE and/or FEDERAL Laws and Regulations. As the undersigned owner,operator,oragent of the property located at the above facility/site address,1 hereby authorize the release of <br /> my and all results and environmental assessment information to SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br /> rrovided to me or my representative. n <br /> � ,sEPRINi <br /> APPLICANT NAME (yT SIGNATURE f(/ <br /> TITLE /���/.p ,,�//7 / / '(' may{/'/�•fp / �J1 DRIVER'S LICENSE# U�//r/ (� <br /> ',e,AW ale,_ / oie6 / ae'o 7IJI eHOTOCO%REOUIREO) � 5 (�`f7� / <br /> Approved By Date Accounting Office Processing completed ByO—C�— Data �� <br />