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r <br /> San AM County Environmental HealthD�artment <br /> DATE GREEN FORM <br /> 5R4MASTER FILE RECORD INFORMATION "MFR" <br /> OWNER ID# bCASE# UNIT IV <br /> l.t)Ob15 5 <br /> OWNER FILE <br /> COMPLETE rHEFOLLO.W1ING PROPERTY OWNER INFORMATION; CHECeIF OWNER CVRRE.YrcroRFfLEM EHD ❑ <br /> 7Owner <br /> ERNAME oe S , rfn PHONE <br /> zo <br /> Firs MI Last <br /> (l,S. SCCSEC/TAZID# <br /> AddD RAS LICENSE# <br /> (2o�if � <br /> Clty L STATE <br /> CAzip <br /> S 30 <br /> Owner Mailing Address <br /> Mailing Address City O <br /> VOW / <br /> ,t��T S _ <br /> C —QC- AJ State/1 Ztp pS n <br /> CORPORATION❑ INDMDUALPAR <br /> ❑ �ryla <br /> TNERSHIP❑ FED AGENCY yy <br /> / OTHER El <br /> FACILITY FILE <br /> FACILITY ID# O 1 0y 1 CROSS REF ID, ACCOUNT ID# INV# <br /> O 1 '� 2b 2 <br /> =E)aSTINI <br /> WI N R ATI <br /> LBUSINESS/FACI <br /> OCATION not pre riousiv regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ No <br /> ess LOCrATTION but a NEW TYPE Of regulatedBusiness? YES ❑ NO <br /> /SITE NAME I 1 <br /> DDRE) Ro r* PO Sum I &lIf — 2 <br /> STATE ZIP <br /> nMailingAdd <br /> 1500.DISTRICT LOCATION CODE REYt KEY2 <br /> iff ETITUAD Fad/' Address AttenJt'pn; Care Ot donaQ <br /> Mailing Address City c/—O <br /> �T2 <br /> CCODE APN# <br /> COMMENT; <br /> THIRD PARTY BILLING INFO: completed Billing Party i5 different from Property Owner or Facility Operator identified above. <br /> BUSINEsSNAME Attention:or Care (optional) <br /> Mailing Address Su'i cep,7x-ice. D <br /> � � J �L SuCT'E� l PHDNE � U3( � /U <br /> CITY <br /> lz�ni c�6 CoiZ— cL, - sTATEeA LIP 9S6 70 <br /> "T Da&E;-for fees and Charges OWNER <br /> FACILITY/BUSINESS THIRD PARTY BILLING <br /> R i r A 1,the undersigned Applicant,certify that 1 am the!Tuner,Opeenror,or Aurhuri,eJ Agent this Business,and 1 acknnwled <br /> PENdLT/ES,EVEoxcE.vena CR,Ixr,'es and/or Hoo Le that all PExv,r FEES, <br /> xLY C'HARCEs associated with this operation will he billed to me at the address identified above as the 4fC01 N'TADD IVy for this site. 1 also certify that <br /> all information provided on this application is true and correct;and that all regulated activities will be performed in accordance with all applicable SAN JOAQGIs COUsiv 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,l 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 time it is <br /> provided to me or my representative. <br /> APPLICANT NAMEMx M CC AO PLEASE PwNr SIGNATURE <br /> TITLE E ✓ C01JriIEre/ L- DRVESLICNS # <br /> ( EV <br /> O <br /> APprovetl BY �j Date '7 AccnadhM office processing Completed BY Date 3 <br /> 29-02-002 April 25,2003 <br />