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j San JaaIfuin County Environmental Health OlawArtment <br /> GREEN FORM <br /> DATE ( I MASTER FILE RECORD INFORMATION "MFR" <br /> 'JfHBO OWNERID# Tool! X 1,1616 11 CAEE# UNIT IV <br /> 1V OWNER FILE <br /> CNECR IF OWNER CURRENTLrONRrLEW?M END ❑ <br /> COMPLETE THEFOLLOW/NG PROPERTY OW N ER INFORMA TION.' _ <br /> PHONE 70 _� _ qL 31C <br /> PROPERTY OMER NAME <br /> First MI Lasi <br /> Bua uses NAME <br /> DRIVER's LicstaE# +—"'- <br /> Owner Homs Addmaa <br /> ,� STATE ZIP �— <br /> clb <br /> Ovnser Mailing Address `+i 1 1 <br /> Mailing AddreTyPss �f fC1smm�� ��5 �L�—CGu�� <br /> e CORP TIONIp� INMW L P4RTNERSNiP❑ FEDAOEN 1:1 OrN@R❑ <br /> l FACILITY FILE <br /> FACILITY ID# DRasa REF ID# ACCOUNTID# ^ 4D6 0, INV# <br /> F96o1di1�1 1\rL V (J� <br /> COMPLETETHEFOLLOW/NG BUSINESS/FACILITY/SITE INFORMAFIll <br /> IS this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPT.? YES ❑ NO <br /> Is this an EXISTING Business LOCATION but a NEW TYPE Of regulated Business? YES NO/❑ <br /> EIMINESSIFAOlUrylSITE NAME Surf'-B., r a"e L-o W.r <br /> Lu <br /> SREADDRE88 866 <br /> � � j ra c h <br /> esaDE# 'Bpn _P5_ a 3 a <br /> Cm LCSTA7rA ZIP Z'i �Gj <br /> C� L Gr <br /> BONIO OF SUPERVISOR DomucT LOCATION CODE KEr7 KEY2 <br /> Mailing Address//OIFFERENTfrom FwAWAddmss __ Attention:or Cam Of fopr/arrM9 <br /> Mailing Address City STATE -- ZIP �--� <br /> SICOODE APN$1 CtMMtENr: <br /> THIRD PARTY BILLING INFO: Complete ifBilling Party is different from Property Owner or Facility Operator identifiedabove. <br /> Summeus N.ME / 1 'TAC <br /> T /t Attention:WGa/m,Of l0 <br /> pffi7Z / /; <br /> Mailing Addmea O/ �� + PHONE I I S —'� I —Z Slog <br /> / 1 I <br /> CITY S/. v^ w— STATE C�rA ZIP -74VO 7 <br /> •G�rR/�bA'T'Aa_:^ESO for fees and charges OWNER FACILITY/BUSINESS THIRD PARTY BILLING <br /> BILLING AND COMPI.ANQE AORNovyLice meat: 1,the undersigned Applicant,certify that I..the Owner,Opemmr,or Authorized Agent of this Business,and I acknowledge that all PERFIrr FEES <br /> PEVALzrM,ENMR(PMEATCuARGPS andior nOORLYCHARGES.sverated with this Operation will be bieed tome at the address identified above as the Acroy TA for this site. 1 also ecard,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 JOAQM Cc) N Ordinance Codes and/or <br /> Standards and STATE and/or FEDCEAL 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 /> amv and all results and environmental assessment information to SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTM 'T as soon as it is available and at the same time it is <br /> provide)to me or my representative. f (( �j / /f �/� l <br /> APPLICANTNAME !�l (pLJC l Lf�Fop�/Is EPRINr SIGNATURE /2^./1Er..i( <br /> TITLEDRIVER'S LICENSE# <br /> LYC(7/C/r5 L (PHOTOOOPY REQUIRED) I\ C <br /> ApprovedAccounDnR <br /> By L Osie i/Z_i %/s g Ooe Proc seine Completed pf 5 <br /> By l Data 2 S p <br /> 29-02 10/12/07 MASTER FILE RECORD-GREEN <br />