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i <br /> San Juin County Environmental Health•partment <br /> DACE �" GREEN FORM <br /> '�3'Ofo MASTER FILE RECORD INFORMATION "MFRr/ <br /> m.nm.oc..mR Gun cnu OWNER ID# CASE# UNIT IV <br /> OWNER FILE <br /> COMPLETE THE FOLLOWING PROPE 11 TY OWNER INFORMATION; CNEOir F OWNER CURRENRYONFILEWr EHD <br /> PROPERTY OWNER NAME bol W V �ep Q PHONE 209.948.5566 <br /> TFirst MI \/v Last <br /> BusINEBs NAME CT �f A D,37�11C 7c- SOL SEC/ TAX ID# <br /> Owner Home Address <br /> DRI VER'S U CENSE# <br /> City STATE <br /> Owner Mailing Address 15-33 <br /> G <br /> Mailing Address City ®c State Zip <br /> !G. C' gsS�Js <br /> Noc/1G(1W UGPSYIy <br /> CORPORATION❑ INDIVIDUAL❑ PARTNERSHIP El Fm AGENCY <br /> OTHER <br /> FACILITY FILE <br /> FACTu TY I D# t L� 33Q CROSS REFI D# ACCOUNTID# I �(J'C INV# <br /> OMPLETETHEFOLLOWING U SlTFDyFoRmA7Toly., <br /> I s this a NEW Business LOCATI ON not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YE3>q No ❑ <br /> I s this an EXISTING Business LOCATION but a NEW TYPE of regulated Business? YES ❑ No ❑ <br /> BUSINESS/FAO UTy/Sim NAME Gar <br /> SITEAODRESS Ifo I� I SUITE# BU New PHONE <br /> 0709 SS <br /> qT <br /> 5T>ti STATE LP <br /> CA g5 Z.oS <br /> BOARD OF SUPERM SOR DI STRI Cr LOCATI ON CODE KE l Key2 <br /> Mailing Address WDIFFERENTlrom FadlityAddre Attention:or Care Of(optional) <br /> 1'9'33 C. Lr�+OSA 5TV E%— <br /> Mailing Address City STATE ZIP <br /> SToe.t��+J ////rrrr aJSZo� —`f 4( 8 <br /> SIC CODE APN# 0 COMMENT: <br /> THIRD PARTY BILLING INFO: Complete if Billing Party is different from Property Owner or Facility Operator idendfiedabove, <br /> BUSI NESS NAME _ Attention:orCare Of (optional) <br /> Mailing Address PHONE <br /> CITY _ sTATF LP I <br /> ACCQUAT^^n"EK for fees and charges OWNER FACILITY/BUSINESS THIRD PARTY BILLING <br /> RII nD ro <br /> ACKNOwummFuT I,the undersigned Applicant,certify that I am the Orme,Operator,a Authorized Ager of this Businea,and I adcnwledgethat all PERMIT FEES, <br /> PENALTI Es,ENFORCEMENT CHARGES and/or HoLiKy CHARGES associated with thisoperation will be billed tome at the address identified above wtheA=jNTAnnRFfor this dta l alw)unify that <br /> all information provided on this application is true and correct:and that all regulated activities will be performed in aoanrdanee with all applicable SON JOAQUIN COUNTY Ordinance Cods and/or <br /> Standards and STATe and/or FEDERAL Laws and Regulations As the undersigned owner,operator,a agent of the property located at the above fad IIty/site address,I her Eby authorimthe release of <br /> any and all results and Environmental assessne t information to SAN JOAQUIN"COUNTY ENVIRONMENTAL HEALTH DEPARTMENT ass alit is wailableand at the sametime it is <br /> provided to mea my representative. <br /> APPLI CANT NAME1� // PLEA PRINT Ll <br /> D n nA, I'LL) $ 4 � SIGNATURE <br /> TITLE tic n z ru) M Lail a ger DRIVER'S LICENSE# <br /> f PHOTOOOPY REOUI REDI <br /> Approved By Date Accounting Office Processing Completed By Dal. <br /> 'A2-002 April 25,2003 <br />