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• • <br /> San Joaquin County Environmental Health Department <br /> rr GREEN FORM <br /> "'� Ip b MASTER FILE RECORD INFORMATION "MFR" <br /> Fn A. mo can„cr nu,v OWNER ID# CASE At UNIT IV <br /> OWNER FILE <br /> COMPLE7E7NEFOLLOWING PROPERTY OWNER INFORMATION; CHECKJF OWNER CURRENrtroiv QE BOTH EHD <br /> PROpeRw OYMERNAme T AUR1 • ONE I� Z <br /> U��1' PHONE <br /> MI Last 7 OOC <br /> Bumm NAME SoC SEc/TAx ID# <br /> e <br /> Owner Home Address DAJvE0.'s LICENSE# <br /> Cityn STATE <br /> Owner Mailing Address <br /> Mailing Address City /--� t state " zip ` <br /> TYaE rw n,xx <br /> CORPORATIO INDWIDUALPARTNERSHIP❑ FED AGENCY El OTHFA❑ <br /> FACILITY FILE <br /> FAakrY ID At CROSS REF ID# ACCOUNT ID# INV# <br /> MPLE7E 7NEFOLLOKqNG BUSINESS I FACTUTY SITE INFogmmyom, <br /> Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? yesElNo <br /> Is this an EKIsTINO Business LOCATION but a NEW TYPE of regulated Business?1 Z No <br /> BusmEss/FACum/SIrENAME 1 ..n I^ s <br /> SmAmomst; S- n� Js lWW1JJJJ\\\ Sum#r BUSINESS PHONE <br /> C" Zm <br /> STA N <br /> BOARD OF$UPERVLSOR DDirRIa LOGTfON CODE KEYS KEY2 <br /> Mailing Address ifDIFFEREMthan Fad/ityAddrest, Attention:or Cate Of(opobnaQ <br /> Mailing Address CitySTATE/A 7� �y ,Q/// <br /> SIC CODE APN# COMMENT: L•�'F O• <br /> THIRD PARTY BILLING INFO: Complete if Billing Party is differentfromProperty Owner or Facility Operator idena�ed above. <br /> BUSINESS NAME `"�C' <br /> /�r �\ C a\\ / /' O^ 1` Attention:orCdte Of (OpdO/W/f <br /> Mailing Address b 11 Z J 1(( (CL Vena' Yr PHONE ci 31_ OL _ <br /> Cres' 6-�`1` STATIe� n ZIP <br /> _ �oy Rl <br /> euAzADDRf"lffoorrf,\ , <br /> fees and charges OWNER FACILITY/BUSINESS �/'�THIRD PARTY BILLING <br /> I,the undersigned Applicant,certify that 1 am the Owner,Operator,or Authorized Agent of this Business,and I acknowledge that all PERMIT FEES, <br /> PENALTIES,ENFORCEAIENTCHARGES and/or HOURLYCHARGEY associated with this operation will be billed to me at the address identified above As the ACCnIMTAnnaFce for d1is site. I also certify that <br /> all information provided on this application is true and comee end 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 the above facility/site address,I hereby authorize the release of <br /> any and all resole 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 /> ` SE PRINT <br /> APPLICANT NAME PLEA <br /> S Th a Q SIGNATURE <br /> TITLE rel DRIVER'S LICENSE# <br /> 1!0(A 1neF (PHOTOCOPY REOUIRED) <br /> Approved By + Date Acommting Offices Processing Completed By Date f <br /> 29-02-002 April 25,2003 <br />