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San Joaquin County Environmental Health Department GREEN FORM <br /> DATE . q. D MASTER FILE RECORD INFORMATION `�MFRrr UNIT IV <br /> A OWNER ID# 13 y CASE <br /> / OWNER FILE CCNEcarF OWNER Cuaa anymx.ELrtoE wrra END <br /> COMpLEMTHEFOLLOWING ROPERTy OWNER INFORMATION; b Ot 0 a"A-- 7r7f <br /> pROMW OWNER NAME /$'G(� T <br /> MI Last <br /> Fiat <br /> /� <br /> Soc SEC/Tax ID# <br /> BUMNFSs NAME I Ver CA `—•� <br /> DRIVER'S LICENSE# <br /> olmer Horne Address +ems r�} zip S'33 O <br /> ^�E Ca <br /> city < (-GL o o at,�i 4YS9� <br /> Owner Mailing Address Lnm�, �/R(Q ZIP 9 S 3 3 4 <br /> Mailing Address City r a G <br /> ✓ FED AGENCY❑ ODIER❑ <br /> •• eedro�1�{{ INDMDIh1L❑ <br /> PARTNERSHIP❑ <br /> ConpoRanon/q <br /> FACILITY FILE <br /> t �^ INV# <br /> FauLm ID# ,/_�C�O <br /> CROs REF ID# (`1�6�() ACcounT ID# <br /> r1sthis <br /> a NEW Business LOCATION not Previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? yes ❑ No ❑ <br /> YFs ❑ No El <br /> an FKISTING BUSInesS LOCATION blity-a-�NEW/TYPE Df regulated Business?ss/FAcem/ NAM R;;r ,LSlan�s iT0( <br /> /r $Mlle# BUSINESS PHONE A <br /> SITE ADDRESS 30l W. S�-e WVir OO.,�- <br /> „J STATE C4, 73P <br /> CM La}Hro <br /> LOCATION CODE <br /> KEYl KnZ <br /> BDNm OF SUPERVISOR DUTRIrr <br /> Attention:Or Cam Of(0001130 <br /> Mailing Address YfOIFFERENrfiDm FadiityAddress <br /> STATE Zip <br /> Mailing Address City PN# <br /> COMMEN: <br /> SCODE <br /> Comp/eteif Billing Party isdi(ferentfromPropertyOwneroteFacilityantOf (ori"Nif) ed above. <br /> THIRD PARTY BILLING INFO; Attention:DrCare Of (optlona/) <br /> BUSINEss Nme .,+ eo =()C //���.yM1r (J�e�� C <br /> CTI b ^ l��' PHONE W 1 IO <br /> Matiin9 Address / I 8 J"1 f`1 �f. lKJ //�� <br /> O` lvJ � �1 STATE �O` Zip 9 ✓ 3� U <br /> cTIY fC1iC <br /> ..-l..r m BlUiS for fees and charges OWNER <br /> FACILITYIBUSINESS THIRD PARTY BILLING <br /> and 1 acknowledge that ell PE"IT FEED, <br /> DunemrAnnaFcc for this site. 1 also certify that <br /> R n Nr a Nn Cin E T arR Es a mr.H OUR 1,the undersigned Applicant,this <br /> certify tont 1 am the led to Operator,or AR(Nodud Agent of this Business, <br /> PENALTIES,ENFORCEMEMCTIARGFS and/or ROUIILYCIGRGES associated with this operation wBl be bified to me et the address identified above ance with all erformed inapplicable <br /> the SA <br /> all information provided on this application b true and correcq end that all regulated achovie oto wigbe <br /> otthe propelTyaccorlacated at the above fb slily/site addm ss 1 he byy a ltoriee thedreleme of <br /> Standards and STATE and/or FEDERAL Laws and Regulations. As the undersigned owner, p g a so as t' a Table and at the same time it is <br /> any and all result and environmental assessment information to SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPART <br /> provided to me or my representative. /� p eacF PRINT SIGNATURE <br /> APPLICANT NAME RICNfl20 CTAnbol4o AIR — <br /> TITLE J� ( //� /1' DRIVER'S LICENSE# _ <br /> StVC� l�eOl�Is` (PHOTOCOPYREOUDtED, <br /> ppprovetl BY Date Assnuntln9 Office processing l;gnpleted BY DAte <br /> 29-02-002 ApHI25,2003 <br />