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0 0 <br /> San Joaquin County Environmental Health Department <br /> GREEN FORM <br /> DATE MASTER FILE RECORD INFORMATION IAMFRF' <br /> <..aM.... ,runne'tnov OwNM10# CASEUNIT IV <br /> OWNER FILE <br /> COMPLETE THEF00014TAAG PROPERTY OWNER INF•ORMA710N: CNECNIF OWNER CLf"WTEV`0NRIEtUfDI END <br /> Pa. GeFST r Ted Johnson now 209-599-2151 <br /> First All Last <br /> City of Ripon <br /> SOCSEc/Tax ID# <br /> Owner Home Address DRfaet'SLiaN x <br /> City STATE ZIP i. <br /> Owner Nalling Address 259 North Wilma Ave <br /> Mailing Address City Ripon State CA zip 95366 <br /> Tvea essm.ave...o <br /> NRvwt.ATtoN❑ DsofvswsAt❑ PuaTNetss®❑ RMAcEr 0 OTHER❑ , <br /> FACILITY FILE _ <br /> FAatm ID# CROSS REF ID x Aaouxr m# Itrvx <br /> PLETEON <br /> Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? Yrs ❑ No 121 <br /> Is this an E)asTBVG Business LornTION but a NEW TYPE of regulated Business? YEs ❑ No <br /> BOsmFss/FAmrTr/STrE NArAE City of Ripon WWTF <br /> i <br /> S EADORaR 1210 South Vera Ave SVI,E# <br /> 1209) <br /> 599-2151 <br /> Cm Ripon sTATE CA rs 95366 <br /> i <br /> Bowan OFSUPkRV150R DtSTRIcr IAGnoNCODE REt1 REY2 <br /> Maifing AddressffDIFFEREIYrfrum FaoWWAddress• Attention:or fare Of(ophunaQ <br /> Mailing Address City STATE ZtP <br /> SIC NDE APN x C l Ehs: <br /> THIRD PARTY BILL,IN 13 INPC: Completetf Billing Party Is di ftyentffom Property Owner or Facility Operator h*ew edeboue. <br /> BI15TIiESSNAME Attention:arcane Of(optional) i <br /> i <br /> Mailing Address RwHa <br /> CITY STATE zw <br /> l <br /> Arrwarrwnneecs for fees and charges OWNER FACILI MUSINESS T}gRD PARTY BWJNG <br /> rsn s Inr+vT rnsrythe Undersigned Applicant,cerci that I am tbeOann,Operator,orAofhorkedAgent of this Business,and I acknowledge that a1lPmwr FY.rc, <br /> Pen InW',ENFaaeexLVrCtuAGFsaodkr Ho FCMaR Rsaiated sriththis operodonmN be billed to use at the address identified sbomas the Arrot m4aaaEtt'for this site. I alsocertify that <br /> all information pmsided on Itis application is true and correct;and that all regalNM activities will be performed in accordance svith all applicable SV JOAQuss CQtn�Ordinance Codes aadkr <br /> Standards and SrATE amBor htarJLlT.La s and Reptatkm As the undersiTped owmr,operator,or*gnat of the property located at the above facility/site address,thereby eathorhe the mime of <br /> aqv and all results and emimnmemal assevment Inds madon to SAN JOAQUIN COUN"MUCINNIEN7AL HEALTH DEPARTAIENT 0 soon as it is maaeble and at the same lime it Is, <br /> pmsided tome or my representallm <br /> APPLICANTNAME REASE SIGNATURE <br /> Cil i C)f Rlna�( r�P' fouKg���r <br /> TITLE DRIVER'S LICENSE# <br /> fy t3 L I C �021cS D 11L$E C o t2 (PHmot'ovr•trcQufREu) <br /> l P; ed by Date Aaewrying ORke Prososing Completed eY Date <br /> 29-02-002 Aprtl25,2003 <br />