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San Joaquin County Environmental Health Department GREEN FORM <br /> DATE MASTER FILE RECORD INFORMATION ''MFR" Al <br /> OWNER ID# CASE# UNIT <br /> IV <br /> OWNER FILE <br /> CxtrarrF OWNER LURReNnr ON arta WTTREHD ❑ <br /> COMPLETE THEFOLLOwING PROPERTY OWNER INFORMATION; <br /> PHONE <br /> PROMWOWNER <br /> 2oa - 94 �- 2-C) <br /> NAME <br /> fff <br /> MIBQsfNESS NAME SMSEC/TMID# <br /> NetsDew Pa (tvefs <br /> DRIVER'S LICENSE At <br /> Owner Home Address <br /> STATE ZIP <br /> City <br /> Owner MailiW Address 50"1 W W e tJe'r- A-," <br /> Mailing Acidness City C.k 1ov� Bate CA n0 � 5202 �I <br /> freoneenn <br /> x' Txnrvmusl❑ DeeTxfYOrrP Ccn dncury I. llTxcu 1 <br /> FACILITY ID# CRO55 REF ID# <br /> AccounrID# <br /> Im'# <br /> MPL THEE LLO 55 IF FACILITY I SUEFOR A N' <br /> No <br /> Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? <br /> VEs ❑ <br /> VES El NO <br /> Is this an EsosrinO Business LOCATION but a NEW TYPE of regulated Business? <br /> Busasess/PAcum/SnENAME Det+o- A o-f-"-mQY�n <br /> SIZE ADORE55 ^ .` SURE# BUSINEWPHONE <br /> 90 <br /> CRY S 1 V TLS STATE CA <br /> ZIP �L S 2.0 3 <br /> IIBOARD of SUPERVLSOR DrsTRlcr I I LOCATION CODE I I KEYS I(EVZ_ <br /> Mailing Address ifDPFFEREArfmm FadlityAddress Attention:Or Care Of(OPNona() <br /> 5 o'1 W. W2ba-r A'xf <br /> Mailing Address City 5'b STATE CA W 9 S'LO Z <br /> SIC Coce J APN# COMMENT: <br /> THIRD PARTY BILLING INFO: Complete if Billing Party is different from Property Owner or Facility Operator identifiedabove. <br /> eusrness NAME Attention:orCare Of (op#tTrfa/) / orc�— <br /> Ec,�� -cert (� <br /> Mailing Address (055 u,vilve&54� )4qt , SU. Arc a55 PHONE 9I(o-929-4ILI3 Y2- <br /> STATE <br /> ZSTATE CA ZIP 45&zS <br /> CITY Saci oLMeK+0 <br /> ACCOVIVE"RESsfor fees and charges OWNER FACILITVIBUSINESS TMIRDPARTYBILLING <br /> BIT LINO AND rONIPI TANCE ACKNOWIv Cray: L the undersigned Applicant,certify that I am the owner,operator,or Autheri ed Agent of this Business,and t acknowledge that all PERMIT FEES, <br /> PENALTIES,ENFORCEMENT CHARGES and/or HOURLY CHARGES associated with this operation will be billed to me at the address idendfsed above as the ACCOUNT ADDRESS for this site. 1 also certify that <br /> all information provided on this application is true and correct;and that all regulated activities win be performed in accordance with all applicable SAN JOAQUIN COUNTS 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 authorbc the release of <br /> any and all results and environmental assessment information to SAN JOAQUIN COUNTY ENVHiONMENTAL HEALTH DEPARTMENT as won IN it is available and at the same time it is <br /> provided to me or my representative. <br /> PLEASE PRIM <br /> APPLICANT NAME L04-CIC—:- ICi� SIGNATURE <br /> 1 Tp ^ DRIVER'S LICENSE# <br /> TITLE `j Qi(`I O 't ej' �Q„ 1V` \ C C.Av� (PHOTOCOPY REODIREDI <br /> Approved BY \ Date A000unthsg Office Processing Completed BY Date <br />