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v <br /> San Joaquin County Environmental Health Department <br /> DATE <br /> (�> -� oS MASTER FILE RECORD INFORMATION "MFR" GREEN FORM <br /> VM OWHlgt ID# <br /> GBE# UNIT IV <br /> OWNER FILE <br /> C0MPLE7ETHEAXL0wrNGPROPERTY OWNER INFDRNATION•• 01150(1F OWNNEERpCAeR£WnronPnewm END <br /> MNME <br /> r Lrrf r C PNOaE fY 1 - 7'Z7-3' <br /> -140 <br /> First MI Last <br /> /v 14� Nn- --(L^j E (KK7L1 GTJ SOCSct/TA%IDDRIVER'S Luang:STATE =IP <br /> -OMaiOwner Mailing Address I ZG Q! f _ _1c P-0- <br /> Mailing <br /> ling Address City LoCkv L Bate Lp ��7 <br /> •vsrcrnuueocmay-� w <br /> C01tPORATION RJ INDIV El PARINER9®❑ Fell AGEracr On-ERE] <br /> r` FACILITY FILE <br /> FACDIrY ID# CROSS REF ID# ACCOUNTID# IMV# <br /> COMPILF7F THEFOLL0197NG BUSINESS / FACILITY if SITE INFaRNA770N., 111��� <br /> IS HITS a NEW Business LOCATION not previously regulated Fly the ENVIRONMENTAL HEALTH DEPARTMENT? YES ElNryI... <br /> IS HITS an DUSTING Business LOCATION but a NEW TYPE Of regulated Business? YES ❑ NO <br /> BUSBRESS/FAmm/SOENAME /' <br /> SIZE ADDRESS ' �� 1 O �rV-O- surn:# BUSINES <br /> SSS PMDNE'L�7 <br /> Cm La�}.f �n/.D Il K STATE =P 1 Z JT <br /> BOARDUFSUPERVSORD6TRICT LOUTIONCOOEKEPI KEY= <br /> Mailing Address WDIFFERENTi0sonr Fid/ityAddrEss Attention:or Care Of(DadmaQ <br /> Mailing Address City STATE ZIP, <br /> SIC CODE --][E# <br /> PN# COMMENT: <br /> THIRD PARTY BILLING INFO; Completeif Billing Party is different from Property Owner or Facility Operator identified above. <br /> BIFvINESS NAME Attention:Or Cam Of (Opbro l) <br /> Mailing Address PHONE <br /> Cm STATE ZAP <br /> for fees and Charges OWNER FACILITY/BUSINESS THIRD PARTY BILLING <br /> Bit T INC,ANn CnmM unCP ACENOWI YDPMRNT: 1,the undersigned Applicant,certify that I am the owner.Operator,or Authorised Agent of this Business,and 1 acknowledge that all P£RMITF£ES, <br /> PFNALR£Y,ENPDACEN£M'CHARG£e and/or HOVAYCH lKrassociated with this operation will be billed to..at the address identified above as the 4CCOUATA/MREST for chis site. I afro 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.I hereby authorize the release of <br /> any and all remit 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 NAME Chun L frrLe P"'-PO PLEASE PRINT SIGNATURE <br /> TITLE DRIVER'S LICENSE# <br /> Uzi Ism le N G7 T AN - G (PNOMOOPY REDUIRED) <br /> ApprmiM By Da! Accounting Office Processing Cumulated DY Dad <br /> 29-02-002 A,,,125,2003 <br />