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San ,ruin County Environmental Healthopartment <br /> DATE MASTER FILE RECORD INFORMATION "MFR" GREEN FORM <br /> NOm= UNIT IV <br /> OWNER FILE <br /> CowmEw THEFOLLOWING PROPERTY OWNER lwomfAnon.• Cmcietr OWNER CU M3Wxrawrar.EMTnr END El <br /> PaoPmrYOWNERNAME �r J1/O J J[Y• <br /> '14 0,& J/ PIIorE CYO ) `/S.3 -Q F� d' Y77 <br /> MI Last <br /> BUSINESS NAME ^ SOCSEC/TMIDS <br /> 6i SJ/E C'U ELG >�Ar/ GUR <br /> OYmer Home Addreea gSS SC R.IiietSLICENSES <br /> c c S i C,=g7 DRIv <br /> city � <br /> U X N/ a(��/�- STATE <br /> Owner Malum AEarm s (J <br /> Mailing Address City State ZIP <br /> CORPonanoN❑ INDMDDAL❑ PARINRSHIP❑ FEgAttENCY❑ CITHEI❑ <br /> FACILITY FILE <br /> FACILITY ID i Giros REF ID i Accoutir ID i INYA <br /> COARRI E7E THE FOLLOWING BUSINESS t FACILITY/SITE/NFORAIA7r0M• <br /> IS this a NEW Business LOCATION nOt Pregiuusly regulated by the ENVIRONMENTAL HEALTH DEPT,? YES ❑ NO ❑ <br /> Is this an EXISTING Business LOCATION but NEW TYPE of regulated Business? Yet ❑ No ❑ <br /> SufmasssIFACturYISOE NAME <br /> SHEADDn®s 2 Sum# BUSINESS PHONE y�--3 EJ JI LU v �:Je /} L� <br /> C Y <br /> �/pn Ae STATE LP <br /> SOARDOFSUPERVISOROISIRICT LOCATION CODE REY1 KEY2 L_ <br /> Mailing Address ND/FFEREW15`VV lFacANj Addnn s Ate:car Care Of( ) <br /> N <br /> Mailing Address City <br /> STATE ZIP <br /> SIC CODE APNf <br /> COMMENr: 'rl <br /> THIRD PARTY BILLING INFO: Comp/ete if Billing Party is different from Property Owner or Facility Operator identifiedabove_ <br /> BUSINESS NAME16j67 Abandon:orCare Of(opNonag <br /> GJ ru <br /> Mailhg Addreae <br /> Spiv N 46.05ce ocn,, l{'�, -01.2 PHONE (3 /d) 6 Yti-J'.I"J <br /> CITY G M L.4 6(, <br /> STATE T jJp L O <br /> dDBZIMQdODRE55 for fees and charges OWNER FACILITY/BUSINESS THIRD PARTY&LUNG <br /> BILLING AND COMPLIANCE ACENOWLEra'MENT: 1,the undersigned Applicant,certify,that 1 am the Owner,Operator,or Authorized Agem of this Business,and 1 acknowledge that all PERAfnFEES, <br /> PENALnE$ENFOEL'Esr A CMM-'ES aOd/oe ROURtYC/uRGES associated with this Operadon will be billed to me at the address identified above as the A VI)ATADDR ss for this sit, 1 also certify that <br /> all information provided on this application is troe 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 SrATE and/or FEDERAL laws and Regulations As the undersigned owner,operator,or agent of the property located at the above facility/site address,l hereby authari c the release of <br /> any and all results and environmental assessment information N SAN JOAQUIN COETNTY ENVIRONMENTAL HEAL'I II DEPARTMENT as soon as it is available and at the same time it is <br /> provided M me or my representative. / <br /> APPLICANT NAME �L{ /I e (�(//h/ PLEASE PRINT SIGNATURE <br /> 2 rL� <br /> ��� cK �8 <br /> TITLE Sf�� DRIVER'S LICENSEi enrv✓ /'erg /�tr, , oS��— X15 32411 ?� <br /> PH TOCOPY REOUIREDI <br /> APProves BY <br /> Data Accu Ing Office Processing Completes By <br /> 29-02 10/12/07 UU111F 11 BUEE 1h 11111 <br /> TER FILE RECORD-GREEN <br />