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San Jc--uin County Environmental Health partment <br /> GREEN FORM <br /> DATE1� MASTER FILE RECORD INFORMATION "MFR" <br /> ,Henan ARFAc FnR FHn usF nN1 v OWNER ID# CASE# UNIT IV <br /> OWNER FILE <br /> COMPLETETHEFOLLOWINGPROPERTY OWNER INFORMATION: CH,,orw OWNER CuRRENnyoNFrLEWrn/EHD <br /> El <br /> PROPERTY OWNER NAME PHONE n q •{„t v 2, <br /> First MI I Last <br /> BUSINESS NAME Sot Sec/TAx ID# <br /> �o t' o o t,.� �•/� <br /> Owner Home Address 2 O ` 1 1 DRIVER'S LICENSE# <br /> City STATE f /1 ZIP <br /> Owner Mailing Address <br /> Mailing Address City State Zip <br /> F CIF OWNFRCHTR <br /> CORPORATION❑ INDDaDUAL❑ PARTNERSHIP❑ FED AGENCY❑ OTHER <br /> FACILITY FILE <br /> FACILITY ID# ( CROSS REF ID# ACCOUNT ID# INV# <br /> COMPLETE THEF LL WING BUSINESS I FACILITY I SITE INFORMATI N' <br /> Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ No'5Z <br /> Is this an EXISTING Business LOCATION but a NEW TYPE of regulated Business? YES ❑ No <br /> BUSINESS/FACILm'/SITE NAME <br /> SITE ADDRESS '` L . (� V 6 SUITE# BUSINESS PHONE <br /> CITY 'E�'"` ^ C 1 STATE C I ZIP Q z.a } <br /> BOARD OF SUPERVISOR DISTRICT ✓ACT LOCATION CODE KEY? KEY2 J� \ 3 <br /> Mailing Address/fDIFFEREAITfrom FadlityAddnms Attention:or Care Of(optional) <br /> � o e> '?-% 4; S 4- 5� a <br /> Mailing Address City LAt t A X STATE C_k ZIP at <br /> 4 <br /> SIC CODE APN# COMMENT: <br /> THIRD PARTY BILLING INFO: Complete/f Billing Party is different from Property Owner or Facility Operator identified above. <br /> BUSINESS NAME S J . rt,, A��I FS k S ';- L--1, �"`C- Attention:orCare Of (optional) <br /> I ov amt .►-,... S ,.: � 3 1 <br /> [;�ailingAddress C A PHONE <br /> CITY STATE ZIP pt 4 �� C <br /> erg 1wr Aopo &F for fees and charges OWNER FACILITY/BUSINESS THIRD PARTY BILLING <br /> BIi.i,mr AND COMPI.IANrg Ar.KNOWLEnpMENT: I,the undersigned Applicant,certify that I am the Owner,Operator,or Authorized Agent of this Business,and I acknowledge that all PERMIT REES, <br /> PENAL77Es,ENFORCEMENT CHARGES and/or HOURLYCHARGEY associated with this operation will be billed tome at the address identified above as the A..oar rmn�AnneFac for this site. I also certify 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 JOAQUIN 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, y authorize the release of <br /> any and all results and environmental assessment information to SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTHNT as soon as it is able d at the same time it is <br /> provided to me or my representative. <br /> APPLICANT NAME PLEASE PRINT SIGNATURE <br /> a <br /> TITLE Jj.� DRIVER'S LICE E �[ <br /> fPHOTOCOPYREQUIREDD ry <br /> Approved Bf Date / Accounting Office Processing Completed By G- Date l b l7 <br /> 29-02-002 April 25,2003 <br />