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San Joaquin County Environmental Health Department <br /> r/ <br /> DATE �p b MASTER FILE RECORD INFORMATION "MFR" GREEN FORM <br /> Cuenrn.RUSFax FND osF nxy OWNER ID# 0 � \ CASE# UNIT IV <br /> �✓ OWNER FILE <br /> COMPLETE THEFOLLOHrING PROPERTY OWNER INFORMATION; CMEOra OWN ER CURNENTZYONAELE was EH <br /> PROPERWOWNERNAME T AAJOP% / PHONE '-6 � C <br /> U���First MI Las( <br /> ��GOO <br /> BUSINESS NAME SOCSEC/TAX ID# <br /> Owner Home Address D cvveR's LICENSE# <br /> city n 91-Wt/,4 <br /> TATE Z- q 5fl I 5 <br /> Owner Mailing Address Ar <br /> Mailing Address City t State " Zip \ <br /> nwc nc nw <br /> COIvaRATI INDIvmUAL❑ PARTHERstin,❑ FED AGENCY El OTHER❑ <br /> FACILITY FILE <br /> FACRITv IDAt �sl� OO1Tl�(; CROs REFID# ACCOUNT ID# n fs A Oc�1 INV# ! V-I ? <br /> V3 <br /> MPLETE TNEFOLI-T WING 6 MA O F k} v\11 O l 6 <br /> Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES No <br /> Is this an EXISTING Business LOCATION but a New TYPE of regulated Business?1 YES No ,y <br /> BuSINEss/FAcnJIx/SIZE NAME /`l`'1}�q/t <br /> SIZE ADDRESS S S-0nx J #S sumBUSRIEss PHONE <br /> t <br /> CmSTa 7- O <br /> BOARDOF SUPERvecR DIsraxr LOCATION CODE KEPI KEr2 ^V <br /> I <br /> Mailing Address ifOIFFERENTfrofn Faci/ityAddm Attention:or Care Of(optional) <br /> Mailing Address City �im STATE//I Zm ^ <br /> SIL CODE APN# COMMENT: („T yL <br /> THIRD PARTY BILLING INFO; Cofmp�/ete if Billing Party is different Mom Property Owner or Facility Operator identified above. <br /> BUsmiss NAME-1 a \„ A-L 1/ aA � -er Attention:orrare Of (optional) <br /> Mailing Address 4 [ <br /> q6 / rn• ,TJ�'/tWe a 1�^ PHONE ee1— �/'S/�'] <br /> CDY c lG '\ J 1 UI` `W STAtA !7 to/ ;L l J <br /> AccimaNztl2ag"s for fees and charges OWNER FACILITY/BUSINESS THIRD PARTY BILLING <br /> I,the undersigned Applicant,cerfify that 1 am the Owner,Opernlor,or Authorized Agenr of this Business,and I eclmowledge that ail PERMIT FEES, <br /> PENALTIES,ENFORCEMENT CHARGES and/or ROUFLYCHARGES associated with this operation will be billed tome at the address Identified above e.5 the Ac ctyr AODREfs far this she. 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 JOAQ1AN COUNTY Ordinance Codes and/or <br /> Standards and SFATE and/or FEDERAL Laws and Regulalione. As the undersigned owner,operator,or agent of the property located at the above facility/site address,I hereby auMorize 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 some time it is <br /> provided to me or my representative. ,/� / <br /> APPLICANT NAME S•'4 fl P LP�,KI SIGNATURE <br /> TITLE DRIVER'S LICENSE# I LarXir-.Ie �6Y'L��' <br /> F•IrL,l lr+� (PNOTOCOPYREOUIRED) _ <br /> Approved By Date Accounting Office Processing Completed By Data <br /> 29-02-002 April 25,2003 <br />