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San Joaquin County Environmental Health Npartment <br /> DATE b 'LLT o MASTER FILE RECORD INFORMATION "MFR" GREEN FORM <br /> CHAnFn ARFec FnR FHn ueF nNi v OWNER ID# CASE# UNIT IV <br /> l.JDO 5 33� <br /> OWNER FILE <br /> COMPLETE THEFOLLOWINGPROPERTY OWNER INFORMATI N: CHECKIF OWNER CURRENTL YON ME WJTH EHD El <br /> PROPERTY OWNER NAMEPHONE /' f7 <br /> v� ` 1 I�f ("r.,•f SS L <br /> First MI Last <br /> BUSINESS NAME C\ U C 2 Q SOC SEC/TAX ID# <br /> V <br /> Owner Home AddressI�� f DRIVER'S LICENSE# <br /> /� <br /> G <br /> City C SPATE � ZIP O <br /> Owner Mailing Address) <br /> S100 , <br /> Mailing Address CityState Zip .� <br /> TYRF nF QWNFRCHT <br /> CORPORATION❑ INDMDUAL❑ PARTNERSHIP❑ FED AGENCY❑ OTHER X I <br /> FACILITY FILE (^y� <br /> FACILITY ID# (�O� 1�1 1 1 CROSS REF ID# 11 1ACCOUNT ID# (� `n INV# a <br /> ML FLL WNQQ FRMATlN' r W <br /> Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ No 14 <br /> Is this an EXISTING Business LOCATION but a NEW TYPE of regulated Business? YES ❑ No lel <br /> BUSINESS/FACILITY/SrrE NAME I / <br /> e- - N T <br /> SITE ADDRESS .L .Q, SUITE# BUSINESS PHONE <br /> c- c c i <br /> CITY STATE ZIP <br /> Corr; a, '3 <br /> BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEY1 KEYZ (/7 <br /> Mailing Address tfDIFFERENTfrom FadlityAddress Attention:or Care Of(optional) J�_f1� <br /> Mailing Address City STATE ZIP �(" 1 <br /> FC-E APN# COMMENT: <br /> THIRD PARTY BILLING INFO: Complete if Billing Party is different from Property Owner or Facility Operator identified above. Qc- <br /> BUSINESS NAME /. ' _ Atte n:Or-Cafe O'f (Opbbwl) <br /> Mailing Address PHONE L 15 <br /> CITY �_. /�- `` ,� ^. ATE 741 <br /> errn,Narennp�ee for fees and charges OWNER FACILITY/BUSINESS THIRD PARTY BILLING <br /> BILLINC AND COMPLIANCE ACKNOWLFDGMFNT: 1,the undersigned Applicant certify that 1 am the(hater,Operator,or Aeuthorized;Igent of this Business,and I acknowledge that all PERM1I/7'FEES, <br /> PENAC7'7E.t',ENFoRCEMENTCHARCES and/or HOURLYCHARGES associated with this operation will be billed to me at the address identified above as the ACCOUNTAnnees'S 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,1 hereby authorize the release of <br /> any and all results and environmental assessment information to SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTNI .'T as soon as it is available and at the same time it is <br /> provided to me or my representative. <br /> PLEASE PRINT <br /> APPLICANT NAME SIGNATURE <br /> ck., tz rro � <br /> TITLE DRIVER'S LICENSE#! <br /> (PHOTOCOPY REOUIrs€ 1 134� 3Goi <br /> Approved By Date Accounting Office Processing Completed By Date \.t) 32 <br /> D <br /> 29-02-002 April 25,2003 <br />