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San Joaquin County Environmental Health Department <br /> GREEN FORM <br /> DATE MASTER FILE RECORD INFORMATION "MFR" '`� u <br /> a.ryDaAUSJ!Q FHn,lSa r 0.141111R IDS �� CASES *i�' NIT IV <br /> PLErF THE FOLLOm G P R W R INFORm rrav; -. <br /> YONF"14077N EHD <br /> PROPERTY OWNER NAME N A pm* (2-o<j> 1744 — 4 Z <br /> First MI Lest <br /> &MNM NAM O I- to A.STe IZ A'SSo C b I(p OKS k�- � I SOC Sec/TAX ID S N A <br /> Owner Home Add.= 1341 w . r2o 8 t N i�-o o b D R i S'� a-� Dave's ucom x tN A <br /> Cul/ SToc K-vv N c A HS zo-7 STATE CA ZIP S Z� <br /> Owner Ma1Nnp Address <br /> Mailing Address City Zip <br /> CORPORATION❑ INDIVIDUAL❑ PARTmmaw❑ FED AWICY❑ OTHER 2;t:/4 <br /> fACILRY 111111 r <br /> FAaLrnt IDS t I S CROs REF ID S AOCOUER IO <br /> ComPLEffmEmao*zw BUSINESS I FACIL A's r:zxfy"wzow <br /> Is tt115 a NEw BUMineSS LOCATION not WvWously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ NO G! �J Jq <br /> Is this an EXISTING Business LocATION but a NEw Type of regulated Business? YES ❑ No U <br /> Buso+Ess/FAmltr/STYE NAME S(R6ti:"� - - J'c Cit)t-s 1 <br /> S-ADOR®M _ - /-� A f< y}� I SUITE* 6 6uSIIl W p..Cm Tc C-`t'-TG►.1 IYVJ V I ( 1 V STATE C k m 9 5 2-1 <br /> BOARD OF SUPERV MOR DM"= LOCATION CODs S T IQYZ KEY2 <br /> Mafling Address MQD9%R&ffi otn►/3cOlyAdoYaa Attention:ar Caro Of(op8larast() <br /> Maiitrg Address City STATE Z& <br /> WC COM APNs l ' l03 (��1 COMMEWr: <br /> THueo p"W SILJJ"Mro: Compkte#'Billing Party &differenthovn Property Owner or Facility Operator iden6fed above. <br /> BumNm NAME S>:FLT Co N v LTI IJ C, , INC , Attention:orcareof (ga&vw) <br /> Mawnq Addross 1 PNorle <br /> CITY >✓ TJv 1p_l DC N 1 c A H S`7b L STATE CA zm C-A S 7- -L <br /> AixammAnnam for fees and charges OWNER FACILITY/BUSINESS THIRD PARTY BILLING <br /> RU I INf.AND('OM►1 IAN(F AOCNOWI FIX:MFVr: 1,the undersigned Applicant,certify that 1 am the(Ener,Operator,or Arthorized Agent of this Business,and 1 acknowledge that all PERAHTFEES, <br /> PENALTIES,ENEYMCYMENTCHARGES and/or HOURLYCHARGEES associated with this operation will be billed to me at the address identified above as the ACTTHIA'TALIORFCC for this site. 1 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 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 results 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. �, y�. r, <br /> APPLICANT NAME S �� G PLEASE SIGNATURE C —�T" i'. O, <br /> TITLE P �I�r1JT / Sc�T -ON�J�T1A}�� IAjC DRIVER'S LICENSES <br /> (PHOToaovr REQuuED) <br /> Appr-vd sr Daft Accow tw O1r"Proc=@h r.- 11',ed a Ola t b O <br /> 29-02-002 Apnl 25,2003 • 0 <br />