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. �Jd�# �S7o57,Golo <br /> San �dquin County Environmental Health•partment <br /> DATE �_?I& MASTER FILE RECORD INFORMATION "MFR" GREEN FORM <br /> SHADED AREAS FOR EHD VOL ONLY OWNER ID# CASE UNIT IV <br /> OW0015`i'� 2 <br /> OVIINER FILE <br /> COMPLETE THEFOLLOW/NG PROPERTY OWNER INFORMATION' CHEcmzF OWNER CuRRENnroNFxEwnm EHD <br /> PROPERTY OWNER NAME I PNONE <br /> YYY First MI Last <br /> BUSINEw NAME Soc SECITAAID# <br /> Owner Home Address � � � � e O DRIVER'e LICENSE# <br /> City t STATE ZIP <br /> Owner Mailing Add. S 0' <br /> Mailing Address City State Zip <br /> CORPORATION❑ INDNIDUAIX PARTNERSHIP❑ FED ADENCY❑ OMER❑ <br /> FACILITY FILE rY <br /> FACILITY ID# DRDss REFID# ADCDUNTID# IHV# I y �2�9 <br /> COMPLETE THEFOLLOW/NG BUSINESS/FACILITY/SITE/NFORMA PON- ` Y <br /> la this a NEW Business LOCATION not preVIO JSIy regulated by the ENVIRONMENTAL HEALTH DEPT.? YES-9 No ❑ <br /> Is this an E%ISTING Business <br /> LOCATION but New TYPE Of regulated Business? YES ❑ No Pr <br /> BUSINEsSIFACILTTYISITENAME Q. JLJ 1 T <br /> Sn-EADDRESS SUITE# BUSINESSPHONE <br /> I AAA <br /> CITY STATE ZIP <br /> BOARDOFSuPERWsORDISTNICT LDcaDoN CODE KEY1 KEY2 <br /> Mailing Addreas fir DIFFERENTponlFadN[yAdd-oca Attention:or Care Of(ophional/ <br /> Mailing Address Clty STATE ZIP <br /> SICCODE APN# COMMENT; <br /> THIRD PARTY BILLING INFO: Complete ifBilling Party is different from Property Owner or Facility Operator identified above. <br /> BUSINERs NAME I ; Attention:orCars Of(ophianal) <br /> Mailing Address PHO <br /> NEV? <br /> CITY STATE zip <br /> ZIP 9(! <br /> A cru RTAaRg eR for fees and charges OWNER FACILITY/BUSINESS THIRD PARTY BILLING <br /> BILLING AND COMPLIANCE Ar"ON'LEDGMENT: 1,the undersigned Applicant,certifythat I am the tamer,Operator,or Authorized Agent of this Business,and 1 acknowledge toot all P£Rull FEES, <br /> PEA'ATTiE.1',Eh'FoRc EMEvf CHAROE.S and/or Huuw.r C//ARGEJ associated with this operation wis be billed tome at the address identified above as the A((OUNTAunRsss for this site. I also certify that <br /> all information provided on this application is true and correct;and that all regulated activities wJ[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 property located at the above facilityAke address,1 herehv authorize the release of <br /> any and all results and environmental assessment information to SAN JOAQUIN CO T(y�pfsry'yfOQp'ry�y,7E1pL H DEPARTMENT as soon as it is ailable and of the same dere it is <br /> providedAPPLICANT <br /> m N NAME <br /> Espresso ve. �I E i't;�I U F I - <br /> APPLICANTNAnME i t�SL�j�/„j���.J�-t /�.P/-S�PLEASEPRINr I,J i Yt ` I E <br /> TITLE lal` iCC 71 6 0/4 rS/ DRIVER'SUCE SE# <br /> PH T OPY R UI T <br /> Ap,mo BY Data automating Office ProcmMg Completed Sit Date 7/ <br /> 29-02 10/12/0'1 MASTER FILE RECORD-GREEN <br />