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San gtlin COtinty Environmental Health Department <br /> ' DATE $. 26 It ff GREEN FORM <br /> MASTER FILE RECORD INFORMATION "MFR <br /> fl <br /> roeatn a OWNER ID# CASE N UNIT IV <br /> OWNER FILE <br /> CHEGRIF OWNER cuRRENnrcNFRE wtrH EHD <br /> COMPLETE INEFOLLOWING RTy OW INFORMATION; <br /> ' <br /> PROPERTY <br /> OWNeaNAME av/Js fMQ�r Taste — P 208)&09—U7Y2- <br /> l First MI Lasf <br /> BtlswFss NAME SOC SEC/TM 1D# <br /> Owner Nome Address �7-IL Joli `1 aM d ORtf DRrvets LtisesE# ` q <br /> °ty Trr.I L ,f sr"m GA Zon 97�! <br /> ' Owner Mailing Addressee -7 lame 1121Sffon'7e ffddreSs <br /> Mailing Address City State Zip <br /> CgIPp1ATRTfI❑ INDNIDIIAL PAmtAW�❑ F®AGDA:Y❑ of o <br /> _ FACILITY FILE <br /> FACILLrY ID# CrtosS REF ID# ADDWMID# INV# <br /> ' Is this a NEW Business LOCATION not Previousty 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 /> ' BUS1N1W/FAC1LDY/Sr1EIN.rM4E n .fl' 1l J <br /> "'An""' <br /> 93to cdG5 1 Gtra^f LMe leo An Y SUtfE# BUSINESS PNDNEQ <br /> CITY Tr r. STATECArID 953? 1 <br /> eoARn OFSUPERYLa'OaDI5iR1CT LOcwrIONCoce K-1 IQY2 �S <br /> ' Mailing Address ffDIFFERENTFra,,,FadlifyAddrerr Attention:or Care Of(opt/onan <br /> a7al Y I S. 4aNLa'L'LeT d <br /> Mailing Address CHyT-r•ac Sr"'�GfI '� 953`JI <br /> ' SLC CureAPN# COMMEM: <br /> THIRD PARTY BILLING INFO: Complete if Billing Party is different from Property Owner or Facility Operator identified above. <br /> BISINDISNAMEW Attention:orCare of (optional) <br /> u I.` I,j, <br /> Mailing Address 34N) W, �kaM✓aaer LVAStAlle F 2D9 )L3Y-?7ZZ- <br /> ' Cm 'DG1C 10/1W STATE CA vP Cfg2-/9 <br /> AcfGO"u;ADD&n for fees and charges OWNER FACILITY/BUSINESS THIRD PARTY BILLING <br /> Hi JNr'ANn Vnmp ANry AMNnW FnC,MFNT: ],the undersigned Applicant,certify that I am the owner,operator,or Aurhnriz dAgent or this Business,and 1 acknowledge that nil P£RAHT FE£y, <br /> P£NA4/ES,ENFORC'EM£MC'HM(,fs ander HOURLYCHAAGWY associated with Ihia operation will be billed to me at the address identined above as the Art nnM'ADDRFce for this site, 1 also certify that <br /> all information pro ided on this epplicniio t is true and correct;and that all regulated activities will be performed in accordance with all applicable SAN JOAQUIN 470 P Ordinance Codes and/or <br /> Standards and STATE end/or FEDERAL Laws and Regulations. As the undersigned owner,operator,or agent of the properly located at the above facility/site address,1 hereby authorize the release of <br /> any and ail results and environmental assessment information to SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon ash is available and at the same time it is <br /> provided tome orN Mreprwenlative. / <br /> APPLICANT NAME Fre d 4f LISP <br /> (�J SIGNATURE <br /> DRIVER'S LICENSE# <br /> fRgrocwf RIODDDI ✓T O' 93 <br /> Apprrwed aY Dnuts Accountbtg OlBee Processing completed By Date <br /> 29-02002 April 25,2003 <br />