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San Joaquin County Environmental Health Department <br /> DATEGREEN FORM <br /> MASTER FILE RECORD INFORMATION it MFR" <br /> SHADED AREa9 FOR EHD USE ONLY OWNER 1011 �Lpbot)'18'� CASE# UNIT IV _ <br /> OWNER FILE <br /> COMPLETETHEFOLLOw/NG PROPERTY OWNER/NFORMAT/ON.' CHeoKlf OWNER CuRRENTLroNFicew1rHEHD <br /> PROPERTY OWNER NAME PHONE ._ 4("1 4'00,L <br /> n First All Las! <br /> BUSINESS NAME / -,1J� SOC SEC 1 TAX 1D# <br /> �7 <br /> Owner Home Address DRIVER'S LICENSE# <br /> City STATE ZIP <br /> Owner Mailing Address i,-� ^1 G� `1�k_r ,t- -7�� <br /> Mailing Address City 1 CA <br /> State 71LA, <br /> P <br /> CORPORATION INDIVIDUAL❑ PARTNERSHIP El FED AGENCY❑ OTHER[I <br /> FACILITY FILE <br /> FACILITY ID# rr CROSS REF ID# ACCOUNT 1D# INV# <br /> COMPLETE THE FOILOwlvG BUS INESS/FAC ILITY/SITE/NFORMAT/ON: <br /> IS this a NEW Business LOCATION not Previously regulated by the ENVIRONMENTAL HEALTH DEPT.? YES ❑ NO <br /> IS this an EXISTING Business LOCATION but a NEW TYPE of regulated Business? YES ❑ No <br /> p/� OV <br /> BUSINESS/FACILITY/SITE NAME ' -0—'k� C e-L`{-��/(.'.. 1 N t <br /> SITEADDRESS ���t c l RC.-\"e �� IZG� SUITE# BUSINESS PHONE <br /> 1 <br /> CITY <br /> STATE /' ZIP �;2_ <br /> l� i-�o ( 1 _ <br /> BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEY1 KiEY2 V) <br /> Mel ng Addrose!/DIFFERENT from Fac//llyAddress 1';� J 0 C- " Attention:or Care Of(option/J <br /> Vb <br /> Mailing Address City 7 ✓ S IC t.4 V C; <br /> Fs--1cco-E <br /> ZIP APN# COMMENT: <br /> THIRD PARTY BILLING INFO: Complete i/Billing Party is different from Property Owner or Facility Operator identirled above. <br /> BUSWE88 NAME <br /> Attention:orCare Of(optlonali rUl 0\0 e rS(•NJ <br /> 1 <br /> Mallin Address PHONE C b <br /> `�_L 5.CI �J <br /> CITY '' ? STATE—��) ZIP <br /> 77orooflEss_Afor fees and charges OWNER FACILITY/BUSINESS THIRD PARTY BILLING <br /> ISD.Ltnc non COMPLIANCE ACKN'o,vt.r:nOan:NT; I,the undersigned Applicant,ceryify tbAl I alit Iirc Oivucr,Operwor,or AullinriLed Agew of this Business,And I acknowledge Ih:a all 111:1ow FF6.S, <br /> Pr.'N.ILnt�S,l:;S'Fout7:'a1r.N1'C11.furr:.S;uullor llauttLvGl.INcts.,'Assodated p ith this operafion NN ill be billed to Ine At tl,e address identified above as tite Acer,uNrAnwtP..xv for(his site. I also certify that <br /> all iurororatiun provided on this appliLation is tl'ne and cm'recl;and Olaf all regulated activities will be performed in accordance with 1111 applicnbic SAN JOAQUIN COUNTY Ordinance Codes and/n' <br /> Standards and ST'AIC and/m'FEDERAL LAws and Regulations. As Ilse undersigned owner,operator,or agcut of the property located at file above facility/site address,I hereby Authorize the release of <br /> any;Ill()all resuhs and cnvironnrcutal asscssntcnt iufornuuirnt to SAN JOAQUIN COUNTY B,NVIRONNIHNTAL HEALI'II DIAIARTAII.i�' AS S</Oil as <br /> it available And at the same time it is <br /> provided to me or lily representative. / { <br /> �+�' LEASE PRINT SIGNATURE <br /> l APPLICANTNAME rS JC r< Y✓�I( ry �)`7-•{ <br /> TITLEI'1 DRIVER'S LICENSE# CJi17�^1iD2�Si fr/V <br /> 1•-, �'� n� I`q �p, r�r�� [,� � (PHOTOCOPY REQUIRED) h' T� <br /> Approvod 6y Dale AccountJng Once Proceeeing Comptelod B Dete �V D <br /> t`tAS 1 LK I II L RI CORD GRt I N <br /> 29-02 10/12/07 <br />