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San Join County Environmental Health <br /> artment <br /> DATE GREEN FORM <br /> JUA/Z `6 74Z MASTER FILE RECORD INFORMATION "MFR" <br /> SHADED ARM Too FRO uce ron OWNER ID# <br /> CASE# UNIT IV <br /> OWNER FILE <br /> COMPLETE THE FOLLOWING PROPERTY OWNER INFORMATION; OIEIXIF OWNER CVRRENMyONFILEWTTPI Eno <br /> PROPERTY OWNER NAME Thy At +-Cn /�'./� -] Q <br /> 1 PHONE �Q <br /> First MI <br /> Las( <br /> BUSINESS NAME 'S+on " r�rv.,�L1,,p <br /> �/+ 1 LrTf Y Ili�� SDC SEC/TAX ID# <br /> Owner Home Addressljc <br /> DRIVEWs LICENSE# N/A <br /> Sty <br /> STATE ZIP <br /> Owner Mailing Address <br /> Mailing Address City <br /> K�ccr, safe ZIP <br /> Tver nc QHMM <br /> CORPORATION❑ INDMDUAL❑ <br /> CAO <br /> PARmERsump❑ FED AGENCY El OMER❑ <br /> G A O �' J 0 _7 v FACILITY FILE 010A\M <br /> FACILDY ID.# CROSS.REF ID At Accoom ID# <br /> hP/# <br /> CAM—PLETETHEFOLLOHEN9srrFR <br /> Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ <br /> No 93 <br /> Is this an EXISTING Business Locpnon but a NEW TYPE of regulated Business? <br /> YES ❑ No Q <br /> BUSINESS/FACILITY/$ITE NAME crr <br /> 1 � tier" <br /> SITE ADOREss n UiC2 <br /> 5gco 1>0(-i IL veinic)c''_ sum At BUSINESS PHONE <br /> CITY &t-0 K1c)nSTATE r��) <br /> /"A � �7 <br /> BOARD OF SUPERVISOR Dlsrw951icr LUCAmoN CODE KEY1 �1 <br /> � <br /> KEY2' <br /> Mailing Add%reIs-s-rWDIFFERENrfrom FacfiityAcia est <br /> cam/ / 1 / m ("�_1 �O" Attention:or Care Of(OPOO a/) <br /> VL ICU fox 1 M9 � t n OC/}L <br /> Mailing Address City Son <br /> 1 vl� 0`,`15190 STATE <br /> L� cJ Cq z'P L40(() <br /> sic CODE APN At <br /> COMMENT. <br /> THIRD PARTY BILLING INFO: Complete/f Billing Party is different from Property Owner or Facility Operator identified above. <br /> BUSiNESs NAME <br /> F Iv itlz _Attention:orCam Of (optional) <br /> Mailing Address V111 ©ild ?lac(E�rvr Ile Ra S-04e a\C) 9/&- tea_ 7,� <br /> PHONE ry�+� <br /> CITY STATE �- ,1 Z'P 9-580-7 <br /> A= 0V-"A «for fees and charges (�. C., <br /> ^ Oe OWNER FACILITY/BUSINESS THIRD PARTY BILLING <br /> 1111LING ANaCalsmelI,the undersigned Applicant,certify that I am the Owner,Operator,or Authorized Agenr of this Bminem,and 1 acknowledge that all P£RMIr FEES, <br /> PENALTIES,ENFORCEMENFCHARGES and/or HOURLY CHARGES associated with this operation will be billed to me at the address identified above as the ACm/rvrAn <br /> information provided on this application is true and correct, and that all regulated activities will be applicable <br /> p for this site. I also certify that all <br /> nce <br /> all <br /> Standards and STATE and/or FYDERAL Laws and Regulations. As the undersigned owner,operator,or gent of he property locatedathe above falcil h/s'ite address,01 herebytauthorize tdinance herelease <br /> any and all results and environmental assessment information to SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon is available and at the sameflimais <br /> provided to me or my representative. <br /> APPLICANT NAME 7 [[ PLEASE PRINT <br /> O'LH lk f Vq1 d:y SIGNATURE <br /> TITLE <br /> /a ' +- �/✓U DRIVER'S LICENSE# <br /> (PHOTOCOPY REQUIRED) <br /> Approoed BY Date <br /> Accounting OMce Processing Completed BY Date <br /> 29-02-002 April 25,2003 <br />