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San Joaquin County Environmental Health Department <br /> OA.rFGREEN FORM <br /> ►dbV �I ? MA_ R FILE RECORD INFORMATION `T R" <br /> G,..mo AaPar FDR FHn o,nuLy _I UNIT IV <br /> OWNER FILE <br /> COMPLETE rHEFOLLOWINGPROPERTY OWNER INFORMATION; CHEMIF OWNER LURRENnrONRLEWf END <br /> PROPERTYOWNERNAME PHONE SIM q31� <br /> /�, }1 �pra�Fiiat A Ml 1- Last L�'G I <br /> BUSINESS NAME rT1goyt avi, a to.., Q `ixt" WVA ti�lYUW *VtWr SDC SEC/TAXID# fI r!- <br /> Owner Home Address Qv D r & tt O DRrvER•s LICENSE# 'IT <br /> city Ll hAQy% D STATE (-A zM 9 5 23 b <br /> Owner Mailing Address 0 i'(Z - <br /> Mailing Address City YI in}��✓,QIP state �a ZIP <br /> T' 85231, <br /> PF or raw ` G� . ` -1 <br /> CORPORATION E-1 INDIVIDUAL 1:1 LitNA}4t� PARTNERSHIP FED AGENCY❑ OTHER❑ <br /> FACILITY FILE <br /> FACILITY ID# CROSS REFI(# ACCOUNT ID# INV# <br /> OMPLETE rHE FOLLOWING NFORMATION' <br /> Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YEs ❑ No� <br /> Is this an EXISTING Business LOCATION but a NEw TYPE of regulated Business? YEs ❑ No,� <br /> BUSINEss/FACILITY/SITE NAME Apt <br /> SITE ADDRESS qp/"�` 1 Qf b <br /> Sum# BURNSPHONE <br /> CITY <br /> STATE dt ZIP <br /> Mailing Address ifI)IFFERENTfrom FadlityAddm" Attention:or Care Of(optional) <br /> Mailing Address City STATE ZIP <br /> THIRD PARTY BILLING INFO; Completeif Billing Party is different from Property Owner or Facility Operator identified above. <br /> BUSINESS NAME rklet Tech Attention:orcare Of (opborrai <br /> �a Mg. 7- ne V'h un ZS <br /> CO Address 64 TR%veer Oaks VaVKwatf.� PHONE Ppn$\23`2—Z/SCO <br /> CTP` Sq'n .1 o X STATE e 4- /ZIP cm- 3 1 <br /> A^^^••^•z^^^^�e for fees and charges OWNER FACILITY/BUSINESS 1.f 'THIRD PARTY BILLING1 <br /> P LLiNr..AND COMP.ANOr ACRNOW rnr.M¢NT: 1,the undersigned Applicant,certify that I am the Owner,Operator,or AudmrizedAgent of this Business,and I acknowledge that all PE ITF=t <br /> PENALTIES,ENFORCWtl CRARGFS and/or Hotsur(7 a aFs associated with this operation will be billed tome at the address identified above as the ActnOI W'AooRrce for this sits 1 also certify that - <br /> CII 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 /> itandards 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,1 hereby authorize the release of <br /> my 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 /> )rovided to me or my representative. <br /> APPLICANT NAME <br /> PtoDeCcoJloC4l�f1 f BL"rV.%t Yt L�O�& NT SIGNATURE B# w <br /> TITLE DRIVER'S DyA(PHOTOCQUIRE <br /> Approved By Date Attoundng ice Processing Completed By Date <br /> '.9-02-002 April 25,2003 <br />