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May. 18. 2007 10:41AM \;• ' ;Z p <br /> San J(,_.Iuin County Environmental Health 6-tiartlment <br /> DATE GREEN FORM <br /> MASTER FILE RECORD INFORMATION ""MFR" <br /> ...... UNIT IV <br /> -Nom saws sas ma Fwn ucs� OWNee,IDh4< CASE <br /> OWMER FILE r� <br /> COMPLETETHEFOLLOWDW PROPERTY OWNER INFORMATION: CNECX¢ OWNER ctRftZN7tY6N AnEwrrrt END <br /> PROPOtTY OWNER RAMP PHONE <br /> First MI Lest <br /> BUSINESS NAM or Sa SEc/TAx 11)# <br /> Owner H ne Address Z o ` 1 •'� DRIVER 4 Lxmse At <br /> cityW STATE a av C <br /> Owner Malllnp Addrem t'> Z q <br /> Mailing Address City State C A Zlp S 2 1 <br /> MWE LIF QWNaas W IP <br /> t:OMCKATEN❑ IMMMUAt❑ PARTHIROW❑ FEoAatwr❑ <br /> FACILITY FILE <br /> FACam ID# 1'41Cambs REF ID# :< INV r <br /> E FOLL wIN <br /> Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTtt DEPARTMENT? YFv)c No ❑ <br /> Is this an Ex nm Busirwsn Lo ATMN but a NEw Tnm of regulated Business? YEs ❑ No ❑ <br /> SUMNEYS/FA/3ITY/SITE NAME <br /> SM ADDResa a J t.J�,� ► StdyE# S EW PHONE l <br /> Cm 1 S�ATf� <br /> m+ <br /> a 5 2a 3 <br /> BOARD 0P Silty WM-7M Dtsrntt:r v r lout>ION Cam* Ion IQ rz <br /> Mailing Add1raw LirDIfFE' ENTfmm r yAA*ft Atlentkwu or Cane Of(opebW <br /> 15 1. kAjI 1��- <br /> Mailing Address City !C � N p STATE t ZEE Vk-S '7 1 <br /> SIC Caw. X52: APN# CoMMe r. <br /> THIRD DARTY BILLING INFO: Compete if Billing Party /s d/fierent from property Owner orFadIIty Operator Identified above. <br /> Btamce55 NAME , Attention:arcate Of <br /> Maul lg Addrms / O ��` , ,• Q FP— <br /> sE <br /> Cm �a 1✓l 0� � �G� SAL f� � —\�S l <br /> atx=0q;• 029W for fees and charges OWNER FACIL"IBUSINESS THRID PARTY BILLING <br /> Rn.I.rnrr.kvn rnNfPI IArerr A13L9oW enra NTi I,the undersigned Applicant,ccrdfy that I am the OhWer,Op&dfar,or Amthmized AgoW of thi.Husiaess,and I Reimowledge tint all P.IXWT FPbs, <br /> PEW77EY,EVF0WZNZWQ 1ftGss And/or j/OL71Lr GU, ow amoalated with dais operation will be billed tome at the addren ideonified above as thedCCaLZ1A==for tbia site. I abo ewft fbat <br /> an Wormatio n provided an fhb application is Ove And corrin;and that all regulated activities will be performed In accordance with all applkable SAY JOAQLTf Coulay Ordi wce Coda and/or <br /> StAndards and STATE And/or FEMIItAL Laws and Aesulationi As the undersigned owner,operator,or ALeot of the property located at the■bare facility/site address,I hereby antharize the release of <br /> any and Ag reaults and envirvomontal assessment information to SAN JOAQU N COUNTY E\'VIRONNW-4TAL UT.ALPARTNIEN'T as woo as it is Availab the same time it is <br /> provided to me or nV reprmentative. <br /> APPLICANT NAME TJPttnng PRIf� SIQNATURE <br /> 4 , u u.er� <br /> TTTLE <br /> DRIVER'S LICENS 1 p <br /> (PlioytlC�raEQUt S'� �� <br /> Apptvved aY Date Accounting ortke Pracmang Currant tad BY wan <br /> 29-02.003 A*25,2003 <br />