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San Auin County Environmental Health apartment <br /> DATE q,�`UJr MASTER FILE RECORD INFORMATION t.:'' GREEN FORM <br /> OWNERID# CASE# UNIT <br /> IV <br /> OWNER FILE r—� <br /> COMPLETE THE FOLLOWING PROPERTY OWNER INFORMATION: CHECKUP OWNER Cusarswz rONmE wlrn EHD u <br /> OWNERE <br /> PHONE x.001-2)33- 3 4 3 4- <br /> First MI Last <br /> (�3SOCSEC/TAx ID#ssczia„J^1� 1[ r• DRIVER'S LICENSE#2v-f STATE ZIP 4. -Z (0 <br /> Owner Mailing Address <br /> Mailing Address City / r <br /> smote �P 4 3� <br /> Tsar nc n <br /> CORPoRATtoN❑ INDIVIDUAL❑ <br /> PARTNERSHtp❑ FED AGENCY❑ OmIX <br /> FACILITY FILE <br /> FAQury ID# CROSS REF ID# Aaounr ID# INV# <br /> Is this a NEW Business LOCATION not Previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? Yes ❑ No <br /> Is this an E)aSTING Business LOCATION but a NEW TYPE of regulated Business? <br /> Yes No ❑ <br /> BusmEss/FaaalrY/$IrE NAME <br /> SITE ADDRESS <br /> ��S✓V ��'.��"� Qn to SUITE# BUSMEss <br /> Cm <br /> 2a�A-�t�353 <br /> STATE ZIP <br /> BOARDOFSUPERVD-ARDISTRRT LOfATION CODE K yj <br /> KEY2 <br /> Mailing Address"IFFERENT'from Fad/itygddr attent, <br /> r <br /> Mailing Address City <br /> STA E ZIP <br /> SIC CODE APN# <br /> COMMENT: <br /> THIRD PARTY BILLING INFO: Complete if Billing Party &dilferentfrom Property Owner or Facility Operator identified above. <br /> BuSINEss NAME r . oxi subv ac 0, C =)'r .Q Attention: CaR Of <br /> I .a L `�t-f� <br /> Mailing Address <br /> �7 a l0-o lea car- <br /> Clrr C�LLJtI�IV..D+.LI _ SATE upci 7�A�J' <br /> 1 <br /> for fees and charges GJ�• l <br /> OWNER FACILITY/BUSINESS THIRD PARTY BILLING <br /> BILLING AN.COMPT LANCF A : 1,the Undersigned Applicant,certify that 1 am the Owner,Operator,or AmMo <br /> PENALTIES,ENFORCFARKTCLARo'£S P NLed Agent of this Business,and Ia owledge that all PEWITF£[s, <br /> and/or RouRLVC'rurccEs assuciahJ with this operation win be billed to. At the address identified as the <br /> all information provided on this application is nue and correct;and that all regulated aeivifies will be performed in accordso certify that <br /> ance with II a pgcab JOAQUEu COMY Ordinancfor this site. I e Codes aad/., <br /> Standards and STATE and/or FEDERAL Laws and Re,I.tions. .As the undersigned owner,operator,or agent of the property located at t e a acility/site address,I hereby authorize the release of <br /> any and all results and environmental assessment information to SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPAR T as soom as it is available and at the same time it is <br /> provided to me or my representative. <br /> APPLICANT NAME �Qj�tL� t'/`. Tt� SIGNATUR <br /> TITLE D <br /> • DRIVER'S LICENSE# a�t C M � <br /> `1 (PNOTOCOPYREOUIRED) p-b-3 W <br /> Approved By Date AecounBng Office Processing Completed By Date <br /> 29-02-002 Apnl 25,2003 <br />