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t <br /> San Joaquin County Environmental Health Department <br /> i a ` <br /> DATE ©�2 I MASTER FILE RECORD INFORMATION ""MFR" GREEN FORM <br /> ,Nan—ARFac Fno FHn ncF nNI v OWNER ID# I 3 CASE# UNIT IV <br /> OWNER FILE n� <br /> COMPLETETHEFOLLOWINGPROPERTY OWNER INFORMATION: OiECKIF OWNER CuRRENnroNfrLEwmt EHD <br /> PROPERTY OWNER NAME �S PHONE <br /> First MI Last 7 <br /> BUSINESS NAME yy�� SOC SEC/TAX ID# <br /> Owner Home Address 0 (� Y y� 2J+ DRIVER'S LICENSE# Q / <br /> city !!! STATE� ZIP / G. / 2 <br /> Owner Mailing Address <br /> Mailing Address City I State Zip <br /> TYPF OF AWNFQCNTY ray, <br /> CORPORATION E] INDMDUAL 11 PARTNERSHIP❑ FED AGENCY❑ OIHERAj 1; <br /> FACILITY FILE <br /> FACILm ID T—LClCA� CROSS REF ID# ][ACCOUNT ID# ? / INV#COMPLETE <br /> rNEFOLLOWN5( J (® 1 f <br /> Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ No'e t <br /> Is this an E)asTING Business LOCATION but a NEW TYPE of regulated Business? YES ❑ No �r <br /> BUSINESS/FACILm/SITE NAME <br /> SITE ADDRESS �7 Z L f,S�'G•'©� ,c SUITE# BUSINESS PHONE <br /> CITY <br /> STA ZIP <br /> BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEY1 KEY2 <br /> Mailing Address ifDIFFERENTirom FadlityAddress Atbention:or Care Of(optional) <br /> Mailing Address City STATE ZIP <br /> SIC CODEa C) Q [APN <br /> # /012— <br /> n/2 / 00 <br /> 2— COMMENT: <br /> THIRD PARTY BILLING INFO: Completeif Billing Party is different from Property Owner or Facility Operator identified above. <br /> BUSINESS NAMEiE, Atbenti0 :or Care Of (Optiorla, l �� <br /> n \ CA (�4 <br /> Mailing Address -7o I ` '`p,,l �Yo [PHONE f l`$ )/ <br /> Cm t ` \ a- l STATE t- pr- ZIP �VLEI L I <br /> � vrennncacvvvafor fees and charges 1, <br /> OWNER FACILITY/BUSINESS THIRD PARTY BILLING <br /> RILI.INC ANn t'OMPLIaNf F Ar KNOW1.FDGMFNT: 1,the undersigned Applicant,certify that 1 am the Owner,Operator, Authorized A ,.-A.f this Business,and 1 acknowledge that all PERMIT FEES, <br /> PENALTIES,ENFORCEMENTCHARGES and/or HOURLY CHARGES associated with this operation will be billed to me at the addr above as the ACCOINTADDRecc 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 ay address,1 her by authorize the release of <br /> any and all results and environmental assessment information to SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTf NT n as it is availab nd a e same time it is <br /> provided to me or my representative. <br /> APPLICANT NAME // [ M ¢s Gra pI case S SIGNATURE <br /> S LICENSE# <br /> TITLE �/"' ` P HOTOCOR'PY REQUIRED <br /> Approved By `— Date Z.� D Accounting Office Processing Completed BY Date Q <br /> 29-02-002 April 25,2003 <br />