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San Joaquin County Environmental Health Department <br /> GREEN FORM <br /> DATE Z _ os MASTER FILE RECORD INFORMATION "MFR£f <br /> caa�EN.aP..Toa PMn n..Rai. <br /> OWNER ID* c' CASE Jf ---- UNIT IV <br /> OWNER FILE <br /> COMPLETE THEFOLLowNG PROPERTY OWNER INFORMATION: LNECKIF OWNER CURRENFLYON£rLe WLTH EHD <br /> PROPERTY OWNER NAME PHONE Z�q CT ZqD <br /> First MI Las( -1 O <br /> BlmnEss NAME SocSEc/TAR ID# <br /> Owner Home Address C �Iv N; DRNER'S LICENSE# <br /> City LcAa.rb JW STATE C'A z" 9S33p <br /> Owner Mailing Address �-T A 5 ��� <br /> Mailing Address City state Zip <br /> Tvac nR nwNFggmT <br /> CORPORATION INDIVIDUAL El PARTNERSHIP❑ Fes AGENCY❑ OTHER 1:1 <br /> FACILITY FILE L y <br /> FACH-TTYID# Y CROSS REF ID# ACCOUNTID# ✓• � INV# <br /> Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? yes ❑ No <br /> Is this an EI¢sTiNG Business LOCATION but a NEW TYPE of regulated Business? yEs ❑ No <br /> BUSINESS/FACRITY/SIIENAMEOC p4 V,I\<- -r I <br /> 1 1 v k� nc�,� C c. <br /> SITE ADDRESS Sob ec _ �� SUITE# BUSINESS PHONE 956 D 6NI <br /> L.IJ li g5T OWs,ejC_ <br /> Cm I c,'h vV STATE ZIP G S 33 <br /> BOARDOFSDPERV1S0RDI5nR1cT LOCATION CODE KEY1 KEY2 <br /> Mailing Address ifOIFFERENTfiom,FaofityAddress Attention:or Care Of(option/) <br /> Mailing Address City STATE zip <br /> SIC CODE APN At _FMMENT:777 <br /> THIRD PARTY BILLING INFO: Completeif Billing Party is different from Property Owner or Facility Operator identiriedabove. - <br /> BUSINESSNAMEC.n.JDr Attention:Or Care Of (optional) <br /> I colAv�ID �s ztAc. �l'e1�f w'lll��� <br /> Mailing Address I,S Fye'` 1 c 1 Cwr lc C I a PHONE Z _ _3l_ DLJ <br /> DItY 5-4of..tc1-obi ^ W T J1.s,T'tC- STATE A ZP g5Zc�6 <br /> for fees and Charges OWNER FACILrfy/BUSINESS THIRD PARTY BILLING <br /> Rn r INC,AND COMP aNro eraN0wr vnraneW' I,the undersigned Applicant,certify that I am the OwneA operator,or Antherired Agent of this Business,and I acknowledge that all PERMITFE£S, <br /> PENALTIES,EN£ORCEMENr CHARGES and/or HOURLY CHARGES associated with this operation will be billed to me at the address identified above as the ACCOIINTADDRFec for this site. I also certify that <br /> all information provided an this application is true and correct;and that all regulated activides will be performed In accordance with all applicable SAN JOAQUIN COUNTY Ordinance Codes and/or <br /> Standards and STATE and/or FEDERAL Laws and Reguladons. As the undersigned owner,operator,or agent of the property located at the above facility/site address,I hereby aufhorire the release of <br /> any and all results and environmental assessment information to SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTM as it is available and at the same here it is <br /> provided to me or my representative. <br /> PLENSE PRINT' <br /> APPLICANT NAME L � �6L�?.r SIGNATOR <br /> TITLE y J•�� DRIVER'S LICEN$ # �[ <br /> C/V✓!/�O,s'NCNr_ L � (PHOTD�DPYREDDIREDT cg 2 o i 34 Z <br /> Approved By Data Attounting Office Processing Completed By Date <br /> 29.02.002 April25,2003 CONFIDENTIAL <br />