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12/31/2009 THU 15: 09 FAX 2094683433 SJC EHD 0002/002 <br /> o <br /> f San Joaquin County Environmental Health Department <br /> DATE I I GREEN FORM <br /> I MASTER FILE RECORD INFORMATION "MFR" <br /> a.ar.ern.can nar n^•3_ OWNER ID# CASE At UNIT IV <br /> OWNER FILE <br /> OMPLETE rNEFOLLOWINGP RTY OWNER INFORMATION; CmEcoem OWNER CnawEHrlrD.vFrtrwrrN END <br /> PROPERTY OWNER NAME PHONE <br /> Last <br /> BUSINEss NAME / Fe, o4 SOC SEC/TAX IO# <br /> Owner Home Address � � DarvEn'sLICENSE# <br /> (+ STA,E!—/"�1Ep <br /> ng ,C 3 <br /> OwnerMalliAddress ( /1 J <br /> Malling Address City State Zip <br /> CORPORATION❑ INDMDUAL❑ PA1n?*VAIIP❑ <br /> FED AGFAIL\'❑ QINErt❑ <br /> FACILITY FILE <br /> FAI ID# CROSS REF IO# ACODurrf ID# INvtt <br /> Is ttus a New Business LOCATION not previously regulated try the ENVIRONMENTAL HEALTH DEPARTMENT? res ❑ No O <br /> Is this an ExisrING Business LOCATION but a NEW TYKE of regulated Business? YEs ❑ No ❑ <br /> BUSMESS/FACILM/RrF NAME <br /> SrTEADDRESS Surrr4f BVSMSSPNowe <br /> CIrY <br /> SPATE ZIP <br /> BOARD of SUPERVISOR DrSEgILT LOCltTTam COOS KEPI KlY2 <br /> Mailing Address ff01FPERENrftm FAIdllfyAddness Attention:or Cate Of(opdoowft <br /> Mailing Address City STATE ZIP <br /> SIC CODE APN# <br /> COMMENTt <br /> THIRD PARTY BILLING INFO; Complete if Billing Party &differentfiomProperty Owner OrFadlity Operabor Mentfttedabove. <br /> BUSINESSNAME�> AtbaRivrr orCare Of(cpoonaft <br /> Mailing Address \ v'Vo- c� (�c.� PHIONEC <br /> CrrY <br /> -12 O C) L^( STATE //� 2,p 2-s?�V <br /> ALCQ Ar 4aaasr r for fees and Charges OWNER O]' <br /> WNER FACI(JTY/RUSINE$S TWRDPARTY BIWNG <br /> nlr s wr.AND f'nan'I 1 N('Arrnntvl rte;asrNT; 1,the undersigned Applicant,ctrtl fy that 1 am the OlxTrr,OPeralor,or Authrwtted Agent of this Business,and I acknowledge that ail MwirF£6, <br /> I'£NA LTIrS,E,vF0Rrr E`NrC7leacrs andtor IlooRtr CRAftrE$associated with IWs operation wol be billed to me at the Address Identilled above as thednmmrrennii <br /> for Mb site,1 also certify that <br /> all infarnufion pravldcd on this g3p11cation h true and carred;and that all regulated activities will be performed N attardaace with all Air SAN JOAQUIN CDUtrTY Ordinance Codes and/or <br /> Standards and STALE anNor PI.11FRAL Laws and Regula Rous.As the undersigned owner,operator,or agent of the property located at the above f ISAN J s,I hereby rdinan authorize the release or <br /> any and all rewlh And environmental Assessment information to SAN JOAQUIN COUNTY ENVIRONfMENTAi,HEALTH DEPARTME <br /> sora it is av A d at the same time it Is <br /> providal to mc,or my rrprne rvL J <br /> APPLICANT NAME / PLEASE PRV1T t <br /> SIGNATURE <br /> I <br /> TITLE <br /> DRIVER'S ETDa)r LICENSE <br /> na1 <br /> Apprdved By Date l ��/(J Aacowting Office hooefshq Comp ahad BY Date <br /> 29-02-002 ttplll/) 2003 <br /> w <br />