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San Jin County Environmental Health �artment <br /> GREEN FORM <br /> °ATE MASTER FILE RECORD INFORMATION "MFR" <br /> cunnrn mcec cnu EHn cr nNv OWNER ID# '�^^ CASE UNIT IV <br /> OW <br /> OWNER FILE <br /> COMPLETE THEFOLLOWINGPROPERTY OWNER INFORMATION: O+EIXFF OWNER LUxRE,m.ravFne wnH EHD F <br /> PROPERTY OWNER NAME PHONE <br /> First MI Last <br /> BUSINESS NAME Soc SEc/TAX ID# <br /> Owner Home Address £ Z A-�xIPO DRIVER'S LICENSE# <br /> C;(y r_ STATE C IA 2]P 3 W <br /> Owner Mailing Aldress <br /> Mailing Address City state( A— Zip GC Z <br /> O l�� 1 J <br /> TV aF nc nWYGRO TP <br /> CORMNATIONA INDIVIDUAL❑ PARTNERSHIP❑ FED AGENCY❑ OTHER❑ <br /> FACILITY FILE <br /> FACILITY ID# Cn CROWREFID# AcwuxT ID# 0 INV# <br /> OMPLETETHE LL WING INFORMATION.' rrp�-t <br /> Is this a NEW Business LOCATION not Previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES El No r19 <br /> IS this an EXISTING Business LOCATION but d NEW TYPE Of regulated Business? YES ❑ NO Vy <br /> BUSINESS/FACILITY/$ITE NAME <br /> OX \ <br /> SIZE ADDRESS SURE# BUSINESS ONE <br /> eo9 s -ai <br /> CrTY STATE f n ZIP qC CO <br /> BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEPI KEY2 <br /> Mailing Address if DIFFERENT from FadiityAddme Attention:or Care Of(opoonaf) <br /> Mailing Address City STATE 21p <br /> SIC CODE APN# COMMENT: <br /> THIRD PARTY BILLING INFO: Complete if Billing Party is different from Property Owner or Facility Operator identified above. <br /> Busimss NAME Attention:orCare Of (opCorwQ <br /> —1 <br /> Y \ <br /> Mailing Address CC�q1,inr.—I l,� v l V\C O]✓ T� PHONE co W, � Itlu,)gS6 <br /> CITY ap(A lCL�11 � II STATE zip 7/`f6C2 2 <br /> 4CC,Qwr Annnccc for fees and charges OWNER FACILITY/BUSINESS THIRD PART BILLING <br /> Rn r.Nr AND Compi,EANrE ArRNnwEEDGMENT: I,the undersigned Applicant,certify that I am the Owner,Operator,or AutfmrcWdAgenr of this Business,and 1 acknowledge that all PERM/1'FEEc, <br /> PENALTIES,ENFORCEMENfCHARGES and/or HOURLYCHARGES associated with this operation will be billed to me at the address identified above as the AocO,T 'AnnRFe¢for this site. 1 also certify that <br /> all information provided on this application is true and correct;and that all regulated activities will be performed in accordance with all applicable SAN JOAQUINCOUNTY 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,l hereby authorize the release of <br /> any 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 /> provided to me or my representative <br /> PLEA PRSxT <br /> APPLICANT NAME�r i (2- ,; CSF SIGNATURE <br /> s <br /> TITLE / C / I I n�^S� (DpRILICENSE <br /> ry O\TOCOPER SY nEQUIREDt T !SQ t70) L] <br /> Approves]]By O'"'/'is"1N• Data Amounting Office Processing Completed By I� I Date <br /> 70-67.009 Anril15 JOOi <br />