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q San Joan County Environmental Health Department <br /> DATE b ( b� MASTER FILE RECORD INFORMATION "MFR" GREENFORM <br /> SHADED AREAS FOR END USE ONLY OWNER ID# I/. GASE#. UNIT IV <br /> T OWNER FILE <br /> COMPLETE 7HEFOLLOW/NG PROPERTY OWNER/NFORMAT/ON.• CNECK/F OWNER CORREMMYONFitewmf END <br /> PROPERTYOWNER NAME eGr't`* PHONE "'I <br /> f <br /> First MI Last — N/A —/lyS/r7•/ <br /> BUSINESSNAME <br /> AICIRIc Ens it E�E,7/YLIC CoAn q.At /4604 SocsEClTAziD# <br /> Owner Home Address <br /> DRIVER'S LICENSE# <br /> G� STATE ZIP <br /> Owner Meiling Address 7" (1 CALe <br /> / L,JCL Sr. M a I � Co A 13 2 y4 <br /> Mailing Address City Sq tJ r 2q,i./C-1 S CO State G� 2IP y 0 <br /> TYPE DFOweirgaNs, <br /> CORPORATIONpU INDIWCuAL❑ PARTNERSHIP❑ FED AGENCY El OTHER[I <br /> ��{1� FACILITY FILE (yam <br /> FACILITY ID# I�O I CROSS REF ID Is 60 OwIf ACCOUNTID# -53838 <br /> INV# <br /> COMPLETE THEFO`LLOW/NO BUSINESS/FACILITY/SITE/NFORMA T/ON' v,-I <br /> IS this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPT.? YES yam. No ,,❑st <br /> IS this an EXISTING Business LOCATION but a NEW TYPE Of regulated Business? r• _ /I YES ❑ NO I[Y <br /> BUSINESS/FACILlwiSRE NAME PG t F )Z(�C � RLvi LE C1=N,—r=J_ <br /> $ITE ADDRESS ^ 1 r� / 2�,; f T SUITE# BUSINESS PHON <br /> /� C,NF RDap {zo9�4Yz•rr o <br /> CITY I RocSTATE ^ ZIP 91 ,5- 3 -?k, <br /> � <br /> BOARD DF$UPENVISOR DISTRICT LOCATION CODE Kul KEY2 �1 <br /> Meiling Address dO/FFERENTInner,FacifityAddress Attention:or Care Of(opb'orreQ <br /> Mailing Address City A/ n 7 STATE ZIP <br /> SICCODE APN# <br /> t <br /> COMMENT: <br /> vv 'V fI 7.LZ ax•'h <br /> THIRD PARTY BILLING INFO: COLnplete/(BIIIID9 Party is utiii`eretn from Property Owner Or Facility Operator idEnfirle t above. <br /> BUSINESS NAME j^'�/ <br /> Attention:orCare Of(aptiane/) <br /> 7 4DMA s /3CAAfE r, <br /> Mailing Address <br /> 0o W. WALN., ST. I <br /> PHONE CC2(o) f-/Yu ^lv067 <br /> CITY <br /> R S pr D a n+4 STATE C'i ZIP 9 r I a y <br /> AVQWAtrAOORF_ac for fees and charges OWNER FACILITY/BUSINESS THIRD PARTY BILLING <br /> BILLING AND COMPLIANCE ACKNOWLEDGMENT: I,the undersigned Applicanq certify that I am the Owner,Operator,or Authorized Agent of this Business,and I acknowledge that all PERM/TFEES, <br /> PENALTIes,PNFORcEM Gimmes and/or Ifoum.y 0,ARGES associated with this operation will he billed to me at the address identified above as the ACCOOMADDRESS for this site. I 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 JOAQDIN COURTY 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 /> 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. 1 <br /> APPLICANTNAME -r• OAANS sOL,A•Ngy PIFASE PRINT <br /> f SIGNATURE <br /> TITLE {�sA.l�.oha q,� R6ENj Fbn n! d E DRIVER'S LICENSE# �r ' N �)g O <br /> r l7 (PHOTOCOPYREDUIREDI <br /> APPmwxI BY Oate Accounting Office Processing CmnPletad <br /> 29-02 10/12/07 ' RECORD-GREEN <br />