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• 0 <br /> San Joaquin County Environmental Health Department <br /> GREEN FORM <br /> DATE 5�Q DIY MASTER FILE RECORD INFORMATION ''MFR" <br /> cwDOR FMn �enaY OWNER ID# GSE# UNIT IV <br /> OWNER FILE <br /> COMPLETF 7NEFmLOwING PROPERTY OWNER vFoRMATI : <br /> oN � / CNEQYIP OWNER civaREnrzronF wmf EHD <br /> PROPERTY OWNER NAME RIcMf..vD •A /� CLA oAtIV lr1r��FS T e, PHONE �lL.. -49z— 3S�p <br /> First MI Last v <br /> RISINESS NAME AD 0 V C SD[SK/TA%ID# <br /> Owner Home Address 9 2� C> \ O JGLI� �O� S7-,5 <br /> r DMER'S LICENSE# <br /> City ROSE V 1 LLL O STATE zo, y SW I <br /> Owner Mailing Address <br /> Mailing Address City Stave Zip <br /> TwF nc n,u <br /> coRPOMT1oN❑ INDMDUAL❑ PARTNERSHIP FED AGENCY❑ OTHER❑ <br /> FACILITY FILE <br /> FAaLITVID# Co.-REFID# n(f (Ll llAccouNr ID sit 32zy,o Inv# `�01 -r)_C <br /> MP LL HANG [f�N TY SITE <br /> N RMA ` ,JD <br /> Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ No ❑ <br /> Is this an E)(IsnNG Business LOCATION but a NEW TYPE of regulated Business? YES ❑ No ❑ <br /> `/ STWE PROD(i <br /> BUSINESS/FAmnY/SrrE NAME MI_I / ' l —��/ /.ri <br /> SITE ADDREW /122-1/ I t^ /V _ (/� O ,I! BUSINESS PHONE <br /> ON 7 STATE At ZIP <br /> BOARDOFSUMRY DETRICr LOCATION CODE KEYS KEY2 VTI <br /> Mailing Address 1fDD7FRENIf mFad/i VAddRa' Attention:w Care Of(gotitwra/) <br /> Mailing Address City STATE ZID <br /> SIC CODf APN# 23q/30o3 WMMENP. <br /> THIRD PARTY BILLING INFO: Complete/f Billing Party isdifferent from Property Owner or Facility Operator idendffed above. <br /> BUSINEss NAME Attention:wUre Of (olo anod) <br /> Mailing Address PNONE <br /> Cm. STATE ZIP <br /> A4'for fees and charges OWNER FACILITY/BUSINESS THIRD PARTY BILLING <br /> HOT ING AND COMPLIANCE `CRNOW : 1,the undersigned Applicant,certify that I am the Omter,01,ormor,or Authorized Agent of this Business,and I aclmowledge that all PS"Ir FEE, <br /> PENALUES,ENro IcEIENr CmaGEs and/or HOHRIY CHARGE'associated with this operation will be billed tome at the address identified above as the ACCOtTTADDR_for this site 1 also esrtify that <br /> all information provided on this application is true and correct:and that all regulated activities will he performed in accordance with all ap livable SAN JOAQUIN COUNTv Ordinance Coda and/or <br /> Standards and STATE and/or FEDERAL Laws and Regulations. As the undersigned owner,operator,or agent of the property located at th facility/site address,l hereby authorize the release of <br /> any and all resu16 and environmenal assessment informal..To SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEP ME "a.., hle and at the same time it is <br /> provided to me or my representative, pLFASE PRIM <br /> APPLICANT NAMEjV SIGNATURE <br /> TIREV J�-/ �/,/( ..��� DRIVER'S LICENSE# <br /> P�l/JQ / / /Le N/�Ni f/ (I&//A'rJ (PHOTmoo"REQUIRED) <br /> Approved BY Date Accounting Ofice Processing Completed By Dam v0 n <br /> 2902-002 April 25,2003 <br />