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San Joaquin County Environmental Health Department <br /> QATE • � � GREEN FORM <br /> APRT 12l too :MASTER FILE RECORD INFORMAT&pNptt� 4rj#04 <br /> �-orn mmr,c Fists �r ncr n UNIT IV <br /> OWNER FILE <br /> COMPLETE7NEFOLLOWINGPROPERTY OWNER INFORMATLON,• OfEOtIF OWNER czazmsl)tr wF IprrH EHD d <br /> PROPDm OWNER NAME L ' � 9 36 <br /> PHONE �x) 7,-9-15 O <br /> First MI Last 3 —q/fr <br /> stlSDat3S MAME oil F-ANf,'1- SticsEc/rAhcxo# <br /> Owner Home Address DRIVEWS I xcease# <br /> city STATE f 1 <br /> Owner Mailing Address A <br /> Mailing Address City fA OD 1 r State i crZIP <br /> gf07C — <br /> w um <br /> ivnr rnvv Q \ V1JO <br /> CARPDRATI(Ra❑ Xlft) El FED ABesicv othea <br /> FACILITY FILE <br /> FACILITY ID#,.. ' CROSS REDID# ACDOUNT ID <br /> COMPLETE7HEF0Lj0WrNG BUSINESS I FACILITY I SITE LNMAMA770N., OU <br /> Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENis YES ❑ No <br /> Is this an E%ISTTNG Business LOCATION but a NEW TYPE of regulated Business? YES ❑ No <br /> BIAm6S/FAO13W/SITENAs1E 11'x' 6'7',j I _ 1 .. <br /> SITE ADwtEss 6y a !t L ve ve too; Sut re# BnSINESS PHONE 2�R S <br /> p,y yAO, LATE z'p 95a s <br /> Mailing Address WDIFFERENTf tsm Faci/ityAddressAttentlon:a Ura Of(007-1)Abo�< <br /> Mailing Address City STATE ZIP <br /> IF- <br /> THIRD PARTY BILLING INFO; Complete if Billing Party isdiffe2ntfvm Property Owner or Facility Operator identified above. <br /> BUSINESS NAME Attention:oecare Of (Oprown <br /> Mailing Address phswaE �--- <br /> tu <br /> CTTy STATE ^�.bP <br /> for fees and charges QWNER FACILITY/BUSINESS THIRD PARTY BILLING <br /> Nnsmr.ANn rbxmnsN"Ar 10i(10 T mGwvvn I,the undersigned Applicant,certify that I am the Owneq Opermor,or Authorized Agent of this Business,and I acknowledge that all PERaRTFEEB, <br /> PRN UG ,ENPORCEMENICHn Mandlor HOHRIYCHARGFS associated with this operation will be billed to meat me address identified above as theAccosm'r'AnnRecefoT thiSSUL I abo certify that <br /> all information provided on this application is true and correct;and that all regulated acd,iti.will be performed in accordance with all applicable SANJ0AQUS1 CmRTY 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 an results and environmental assessment information to SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEP as soon i 'table and at the same time it is <br /> provided to..or my representative. <br /> APPLICANT NAME I PtEtSE PRaT SIGNATURE f//� <br /> RicNA2n oK, �` < <br /> TITS ��f�eru l 7A r1�/�Q✓ DRIVERS fLICENSEaI D) <br /> Approved By Dole Accounting Office Processing Comdated By Dane <br /> 29-02-002 Apni 25,2003 <br />