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San Je-quin County Environmental Health department <br /> DATE � /O GREEN FORM <br /> M ('ER FILE RECORD INFORMATION MFR" <br /> ` <br /> -T­ 1 <br /> $wencn nacee FnR FHn nes Omv OWNER ID# CASE# I 'v <br /> r It <br /> , <br /> Vit. <br /> OWNER FILE t _l C J 6 2 LEwrrH EHD <br /> COMPLETE THE FOLL 0 WING P RO P E RTY OWNER INFORMATION; K NE <br /> PROPERTY OWNER NAME1(-Yq <br /> e /6 " / 0 111--2, /,/9 C C PHONE <br /> First MI C� 7 Last \J V I L k'—1 [ UME <br /> 4-1- <br /> 6 / <br /> BUSINESS NAME -�� _ I� � A'�^ �/ soc SEC/TAx ID � <br /> Owner Home Address i U ^ e y� „/ DRIVER'S LICENS <br /> City C C- 0 ` STATE C ZIP <br /> Owner Mailing Address <br /> Mailing Address City / (J ✓" (O State Zip <br /> IT'PF AF(�WNFRGNiP X,//I <br /> ' CORPORATIONS T)'. e./✓ INDMDUAL V GLPARTNERSHIP❑ FED AGENCY❑ OTHER❑ <br /> FACILITY FILE <br /> FACILITY ID# CROSS REF ID# ACCOUNT ID# INV# <br /> COMPLErE THEFOLLOWYNG BUSINESS I FACILITY I SITE INFORMATrON.' <br /> Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ No'>< <br /> Is this an EXISTING Business LOCATION but a NEW TYPE of regulated Business? YES ❑ Nom <br /> BUSINESS/FAeILrrY/SrrE NAME �e �V�y"�,J0l� <br /> SITE ADDRESS V r17e' SUITE# BUSINESS PHONE <br /> CITY fl STATE ZIP M <br /> BOARD OF SUPERVISOR DIsmcT LOCATION CODE KEY1 KEY2 / <br /> Mailing Address ifDIFFERENTfromFaci/ifyAddress Attention:or Care Of(optional) <br /> 0- <br /> Mailing Address City STATE zip <br /> SIC CODE 1[APN1# 1[COM�ME . - <br /> 11 <br /> THIRD PARTY BILLING INFO: Comp/ete if Billing Party is different from Property Owner or Facility Operator identified above. <br /> BUSINESS NAME Attention:orCare Of (optional) <br /> Mailing Address PHONE <br /> CITY STATE ZIP <br /> WCWArreDPAE9F for fees and charges OWNER FACILITY/BUSINESS THIRD PARTY BILLING <br /> Rn.I JNf.AND COM1IPIJANfR A('KN(1WLFDGMFNT: I,the undersigned Applicant,certify that I am the Owner,Operator,or Authorized Agent of this Business,and I acknowledge that all PERMIT FEES, <br /> PENALTIES,ENFORCEMENT CHARGES and/or HOURLY CHARGES associated with this Operation will be billed tome at the address identified above as the Ar rQI)ZVT ADnRF..QC for this site. I also certify that all <br /> information provided on this application is true and correct;and that all regulated activities will be performed in accordance with all applicable SAN JOAQurN COUNTY 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. <br /> APPLICANTNAME MPLEASE PRINT SIGNATURE ��,� Qom ✓ <br /> /� ��dAj ��n/� AGES 6 <br /> TITLE DRIVER'S LICENSE# <br /> fPHOTOCOPY REQUIRED) <br /> APProved BY Date Accounting Office Processing Completed By Date <br /> 29-02-002 April 25,2003 <br />