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San auin County Environmental Health L .,artment <br /> f� �0� GREEN FORM <br /> DATE MASTER FILE RECORD INFORMATION "MFR" <br /> CNAnFn ARFAc Eng FHn ocF nN,v OWNER ID# CASE# UNIT IV <br /> OWNER FILE <br /> COMPLETE THE FOLLOWING PROPERTY OWNER INFORMATION; OmarL- OWNER CURRENnYovFILEWITH E H D El <br /> PROPERTY OWNER NAME �lrlsG leu M40 Pq Pf10NE .2oQ- 431-33y� <br /> First MI Last <br /> BUSINESS NAME S4-- <br /> ��Q SOC SEC/TAx ID# <br /> Owner Home Address45-7o Q /V A f e r414q w Q. s DRIVER'S LICENSE# <br /> city Sf-e c k7�o Al / STATE C Al ZIP <br /> Owner Mailing Address <br /> Mailing Address City s a'VAR_ State Zip <br /> TYPE nF OwNFRGNip <br /> CORPORATION❑ INDIVIDUALTi PARiNERSTI❑ FED AGENCY❑ OTHER❑ <br /> _ FACILITY FILE <br /> FACILTrY ID# CROSS REF ID# ACCOUNT ID# INV# <br /> COMPLETE THEFOLLOWNG BUSINESS I FACILITY SITE INFogmwyom <br /> Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ No 3S <br /> Is this an EXISTING Business LOCATION but a NEW TYPE of regulated Business? YES ❑ No <br /> BUSINESS/FACDm/SITE NAME • �r ,S 7/ O <br /> e <br /> SITE ADDRESS 5-769 _IO e • ' 17 �L SUITE# BUSINESS PHONE <br /> QTY 9-Fb C R 4-0 A/ STATE, A ZIP "I t?_; 7, G� <br /> BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEY1 KEY2 <br /> Mailing Address if DIFFERENT from Facility Address Attention:or Care Of(optional) <br /> Mailing Address City STATE ZIP <br /> ---]SIC CODE APN# COMMENT: <br /> THIRD PARTY BILLING INFO: Complete if Billing Party is different from Property Owner or Facility Operator identified above. <br /> BUSINESS NAME Attention:or Care Of (optional) <br /> Mailing Address t,.,/A PHONE <br /> CITY STATE ZIP <br /> Ac�rcccc for fees and charges <br /> OWNER FACILITY/BUSINESS THIRD PARTY BILLING <br /> IUIJJNc AND('OMPLIANCF AfKNOWt.FtN:MFNT: I,the undersigned Applicant,certify that 1 am the Owner,(fierator,or Authorized Agent of this Business,and 1 acknowledge that all PERMIT FEES, <br /> PENAL17ES,ENFORCEMENT CHAR(,'ES and/or HOURLY CHARGES associated with this operation will be billed tome at the address identified above as the ACCV NTr ADDRFcc for this site. I 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 JOAQUIN COUNTY 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 We above facility/site address,1 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. C <br /> APPLICANT NAME Crt i 9-�SN PRm,/�A-T`L SIGNATURE �W�pj <br /> TITLE DRIVER'S LICENSE# <br /> TT l� MO—' E L_ (PHOTOCOPY REQUIRED) [� <br /> Approved By Date Accounting Office Processing Completed By Date <br /> 29-02-002 April 25,2003 <br />