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San Joaquin County Environmental Health Department <br /> DATE MASTER FILE RECORD INFORMATION ""MFR" GREEN FORM <br /> SNGnrn ague Fag FHn jjsF nNt Y OWNER ID# GSE# UNIT IV <br /> OWNER FILE <br /> COMPLETE THEFOLLOWINGPROPERTY OWNER INFORMATION; CHEcxrF OWNER CURRENTLYONFILEWITH EHD <br /> PROPERTY OWNER CNAME J 1 �`� Cti Ill. rD� PHONE" ® 2ai- 4 <br /> First M/ bast <br /> BUSINESS NAME Q "I, <br /> f✓1 O S Soc SEc/TAx ID# <br /> Owner Home Address 0!0 O ry 1 yt( f �,f way , <br /> 5"4- _i j/Q0 y- DRIVER'S LICENSE# <br /> cit'' J �t\C-k ('��l� STATE t :.'J <br /> Owner Mailing Address <br /> Mailing Address City V` State Zip <br /> T'DF nF nWNFRSHF- ID <br /> CORPORATION INDIVIDUAL❑ PARTNERSHIP❑ FED AGENCY❑ <br /> OTHER❑ <br /> FACILITY FILE <br /> FAQLm ID# �r\D'Q�Q [CROSS REF ID# F ACcoVNT ID# INV# <br /> I - <br /> COMPLE7F THEFOLLOWING BUSINESS I FACILITY I SITE rNVORMAWN,' <br /> Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ No Q <br /> Is this an DasTiNG Business LOCATION but a NEW TYPE of regulated Business? YES ❑ No Q <br /> BUSINESS/FACILTrY/SITE <br /> 1. <br /> SITE ADDRESS <br /> SUITE# BUSINESS PHONE <br /> 4 <br /> CTry STATE ZIP <br /> BOARDOFSUPERVISORDMmcr LOCATION CODE KEY1 KEY2 <br /> Mailing Address ifDIFFERENThom FadlityAddress Attention:or Care Of(optional) <br /> Mailing Address City STATE ZIP <br /> SIC CODE APN# COMMENT: <br /> THIRD PARTY BILLING INFO: Complete if Billing Party is different from Property Owner or Facility Operator identified above. <br /> BUSINESS NAME <br /> K I e,1,1 fzl �r Wt,,,)f ) 1 , E � Attention:orCareof (optional) <br /> KilingAddress 2 (1��Z-S' ME• j r 1 I e ST PHONE 2 Ltq—C1 114� —! 3�� <br /> C— �,^C r\-1-o r`^\ STATE (ft ZTP <br /> ACC01 VLADDR .SY for fees and charges <br /> OWNER FACILITY/BUSINESS THIRD PARTY BILLING <br /> KILLING ANn COMPLIANCF ACENO%VLFn(:MFNT: I,the undersigned Applicant,certify that 1 am the Owner,Operator,or Authorized Agent of this Business,and I sclaowledge that all PERMIT FEES, <br /> PENALTIES,ENFORCEMENTGHARGES and/or lIOURLYCHARGES associated with this operation will be billed to me at the address identified above as the A.CCC)r/NTADDRESC for this site. 12150 certify that <br /> all information provided on this application is true and correct;and that all regulated activities will he 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,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 /> APPLICANT NAMEty n <br /> r� r F-i E PanSIGNATURE <br /> TITLE <br /> T 1 t QJi� DRIVER'S LICENSE# <br /> (PHOTOCOPY REQUIRED) <br /> Approved By Date Accounting Office Processing Completed By Date <br /> 29-02-002 April 25,2003 <br />