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07/06/2006 14:54 NEW (r T PETROLEUM 4 12094683433 NO.190 P002 <br /> San Joaquin County Environmental Health Department N <br /> GREEN FORM 0 <br /> DATE6 (o MASTER FILE RECORD INFORMATION "MFR" A� <br /> UNIT IV <br /> cc aua. <br /> ..y OWNER FILE <br /> pray OWNER[vAAFXRrwYPAF N•lrX END � <br /> C0MPL T?1EF0U0WDVC o6RY {COPE,r OW ER INFORMATION. �/'` <br /> pppOwHER NN4 ars 1 Y\ p D yn` L®, . s <br /> fbat AL1 Lest - <br /> �/�•-/ <br /> Ewell NM+F Nee <br /> Owner Home Address vw �R- Q�(�i(.f�y� DmvatSLmrs+t�S O J 1 U <br /> is <br /> STAR Zap , <br /> City <br /> 00 <br /> l g 31 1 low S rc <br /> Oumx Mailing Adareit � � c� <br /> NPIN,v Address city Ci P �,t r 1 ✓t I „ grebe Ap 61 S D <br /> (iORPOFATiaN <br /> INpiu>v1ArPARrt1EMyaP❑ Fm AG@JG�'❑ �� <br /> FGA CILITYFILE <br /> ' lellhr . :.a?'JIIf ilia .�Y , TFL°.ff'd° <br /> re uldled the ENWRONMENTAL HEALTH DEPARTMENrE Yes El No 11 <br /> Is tha a NEW Business LOCATION not previousry 9 Lf' YEe El No ❑ ' <br /> Is this an EKvnTNs Business LOCATION but a/!NEW ripe cof <br /> regulated Busineo? <br /> 91LSQ656/FACaIIY/91EHAHE I�j VI .1 C I, 'C <br /> Sura# eltSa! A'),A- <br /> O <br /> W <br /> /�r <br /> STAR (a'f pP "17 <br /> an <br /> 1 .�. .r 0 —w F x F47tli V5 F'I rp ,�' <br /> i <br /> J <br /> w � �A^r ��:c� ,�.� I �I's'a r1,I L_. !L',.'I+y:.: I . • N„' - .,, I r ' ' I f. <br /> 2 <br /> Attention:or Care Of(pprlone0 <br /> Sime <br /> Mailing Address City rj/,i,Gi�A6 d1 �A-�ap F <br /> l 1 <br /> � d� I ix ri r. la y ' I 3� 9 �ti�in Tx !I•'')`r 1'1 r rj'41-°'� s,.y,,,i� MIN <br /> 8 <br /> "E.wt'•, IF." . A�{ a•F k3S I .+1i tll �Rlll�,.�'4f ,.�s.lk. �. :'.� `1 ' + ; Iw',qy t4,;rl �IS rl il�9..'fi ,� 5 .�i fac,.:,_.I <br /> THIPM tPAnn 6Lwrdo INFO; �mP/em f Billing Party /s difk rntfrom PropartY Owner or Facility Operator/denbha?alwve. <br /> Atlr;ntlon ++r ram Of /mGauO <br /> sins NA - <br /> Mailing Address <br /> STntE <br /> CHT n " <br /> for fees and dtatges OWNER FACILIT'/B1181NE83 <br /> THIRD PARTY BILLING <br /> 1,the undersigned Applian4 oerlify that I am the Owner,OperNor,or Aalkorlsed Agent of this ausinma,and f acknowledge mat an PEAfO(FtE3, <br /> for this sire (also xrtifY thn <br /> pyyAyrpy,�y/eA��s/v.7CNARG/-candler HOuncYCXARGCf avocialed witM1 fhlo operation will be billed to me al the sddeva Identified above as lh¢dGGdf�d➢AHESs�Ordlmare Codes andfo! <br /> an wormation provided de this appliadon is true and correct;and that all rapdew whit.Nwr obe P rf rrexedI. <br /> property a100 a�the above faeSNry/site ad ddrees,l hereby eamor:m Me release of <br /> Slanderdsadd STARandiorywEMLawsand Raguletiona•Asshe undersigned OWner,ope go <br /> of <br /> any and all faults and envirvtunenal.ssoemant arormation m SAN SOAQUIN COUNTY E"EONT'TENTAL HEALTH DEPART WIT As soon 3 k is anilablo and A d o Game that n a <br /> provided to me Or not repraeotltiva p�Ayp plaNf SIGNATURE <br /> APPLICANT NAMEfolk ` yQ/ <br /> DRIVER'S LICENSE# <br /> TITLE (p1gTOEgns'REQUIRED) <br /> paw AeoouMirg <br /> gales,pndmisli 9tnenpleow eY [aafe <br /> Apws.ed M <br /> 29-OMOZ A96123.2003 <br />