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San Jtfaquin County Environmental Health'Mepartment <br /> DATE GREEN FORM <br /> 7 MASTER FILE RECORD INFORMATION "MFRFF <br /> OWNER ID# ODa�� casE# <br /> UNIT IV <br /> r OWNER FILE <br /> COMPLETE TNEFOLLOWI GPIROPERTY OWNER INFORMA TION; CWECKIF OWNER CURREWnYONAEE xnN EMD ❑ <br /> PROPERTY OWNER NAME L <br /> PRONE <br /> First M1 <br /> Lest <br /> BUSINESS NAME A- <br /> IT StscSEc/TAZ ID# <br /> Owner Home Address NF- <br /> MF- DRIVER'S LSCENSE <br /> sTAjJ! �j// <br /> AT LP / ✓ 7 <br /> (.i <br /> Owner Mailing Address e <br /> clov <br /> Mailing Address City C� <br /> State Zip <br /> CORPORATION❑ INDMDUAL <br /> PARTNERSHIP❑ FED AGENCY❑ OTHER <br /> FACILITY FILE <br /> F aLrTYID# FADo1S4� CROSS REF ID# ACCOUNT ID# INV# <br /> 7 <br /> h-kcaLS(.3 <br /> Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ No <br /> Is this an E)asTING Business LOCATION but a NEW TYPE Of regulated Business? YES ❑ No <br /> BusmEss/FAl]LHY/SITE NAME \t /Jl S ,IYI <br /> SHE ADDRESS ��Lw S # BUSINESS PHON <br /> l � / <br /> CTfY 1 STATEC'A— u° <br /> BOARD OF SUPERVISOR DISTRlLT LOUTIONCODE KEY1 KEY2 <br /> Mailing Address ifDIFFERENTfrom Fa ci ddYess Attention:or Care Of(optional) <br /> Mailing Address City STATE LP <br /> �) SIC CODE APN# COMMENT: <br /> THIRD PARTY BILLING INFO: Comp/ete if Billing Party is different from Property Owner or Facility Operator identified above. <br /> BUSINESS NAME -�US Attention:or Care Of (optional) <br /> i�` 1�i�1� <br /> Mailing Address I �DD � - 1 PHONE <br /> cm STA zip <br /> Ar...UAWAGR&L o for fees and charges OWNER FACILITY/BUSINESS THIRD PARTY BILLING/ <br /> Rnr run Avn Cmrvi i.YrF ArKNOWI FW.NIENT: 1,the undersigned Applicant,certify that I am the Owner,OPerRIOr,or Authorized Agent of this Bminess, PER.nr FEES, <br /> PEYALTIES,EN£ORC£H£Nr L'NARGFS and/or ROOALYCHARGES associated with this operation will be blind tome at the address Identified above as the ACC0U1r4ODafTT for this site. l also cerdfy that <br /> all information provided on this application is we and correct;and that all regulated activities will be performed In accordance with all applicable SANJOAQUIY COu, Ordinance Codes and/or <br /> Standards and STATE and/or FEDERAL Laws and Regulatiom. As the undersigned owner,operator,or agent of the property located at the above facility/site address,l hereby autharize the release of <br /> any and all results and environmental assessment information to SAN JOAQUIN COUNTY ENVIRONNIENTAL HEALTH DEPARTMENT as soon as It is available and at the same time it is <br /> provided to me or my reprexnmtive. <br /> APPLICANT NAME ,I PIEAsePurTr SIGNATURE <br /> TITLE DRIVER'S LICENSE# <br /> (PHOTOCOPY REOUIREDI <br /> Approved BY Date D Accounting Office Pracescing Completed By Date 0�' <br /> '9-02-002 Apn,1122i5,2220003 f•}' <br />