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San Joaquin County Environmental Health Department <br /> GREEN FORM <br /> DATE Z MA'R FILE RECORD INFORMATION `� n <br /> r <br /> F nNv UNIT IV <br /> OWNER FILE <br /> [HECKIF OWNER LLRRENTLYON FTLE wmr EHD <br /> COMPLETETHEFOLLOWINGPROPERTY OWNER INFORMATION; <br /> PHONE zea a <br /> PROPERTY OWNER NAME <br /> First n A MI �pLast 1I�r I <br /> BUSINESS NAME I11�yt lay Cg,/ Q rrt'1-�y LiwU �, t*vt "5\N SOC SEC/TA%ID# ��—�r�l_W <br /> DRIVER'S <br /> Owner Home Address �� y `� l C) LI # <br /> zI[ENSE f/J W <br /> city �, ViAQ.f t STATE (—A uP q J 7-3 t <br /> Owner Mailing Address <br /> �i y4o yl, State �� zip Z 7 <br /> Mailing Address City <br /> TvoE E n Ncucarc pm. <br /> CORPORATION❑ INDIVIDUAL Lt4 PARTNERSHIP�1 FED AGENCY❑ OTHER <br /> FACILITY FILE <br /> FACILITY ID# <br /> CROSS REF ID# ACCOUNT Ip# <br /> OMP ETF THE FOLLOWING NFORMATI —N <br /> is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ NOA <br /> Is this an EXISTING Business LOCATION but a New TYPE of regulated Business? YES ❑ No� <br /> BUSINESS/FACILITY/SITE NAME x <br /> SUITE# BUSINESS PHONE <br /> SITE ADDRESS 100� V <br /> p� I y). <br /> CITY TSTATE CA <br /> zIP <br /> Mailing Address ifDIFFERENTffnm FadWAddms Attention:or Care Of(optional) <br /> STATE ZIP <br /> Mailing Address City <br /> THIRD PARTY BILLING INFO: Complete ng Party rentfrom Property Owner ol-Facility Operator identified above. <br /> Attention:orCare Of (optional <br /> BUSINESS NAME <br /> avklrt Tech Ms. �e ne ,Kun <br /> 6q5 RveY Maks Va K PHONE 232-ZSen <br /> Mailing Address �n T Y l� ��$ — LI1 <br /> CrrY 50.11 S ri� <br /> STATE /1 rl �3P <br /> A=uATAOo W for fees and charges OWNER FACILITY/BUSINESS 1,/'THIRD PARTY BILLING <br /> N` A NOW vnf.MPNT: L the Undersigned Applicant,certify that I am the Owner,Operator,or Authorized Agent of this Business,and I acknowledge that all PENArry FEES, <br /> OMPL[ADF TIES,ENFORC£MEMCf GF and/or RODR(.Y CHARGES associated with this operation will be billed tome at the address identified above as the AXO MTADDFESS for this site. 1 also cerfif)'th8t <br /> dl information provided on this application is true and correct;and that all regulated activities will be performed in accordance with ell applicable SAN JOAQUIN CoUNTv 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 /> 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 /> srovided to me or my representative. PL��EA¢gE PRINT <br /> APPLICANT NAME Bfr�� YtW SIGNATURE � rx4A— <br /> TITLE /!„_I�c�l�`�f I Qek DRIVER'S LICENSE#C(� '1 <br /> ko( (PHOTOCOPY REQUI0.ED� l:r� /V yll�p5�— <br /> Approved By Date Accounting Office Processing Completed By Date <br /> '9.02-002 April 25,2003 <br />