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San Squin County Environmental Health 4partment <br /> GREEN FORM <br /> DAIE MASTER FILE RECORD INFORMATION "'MFRrr <br /> OMER IDfr CAS* UNIT IV <br /> OWNER FILE <br /> G0MA,ETE7HEFOLLoWING RO ER N RINFORmUlo : CA Arr OWNER LvaRr YONFILEWW END <br /> PRDPEa ""T T Ted Johnson PtroNE 209-599-2151 <br /> First Ali Last <br /> rase City of Ripon SDCSEC/T"ID# <br /> Owner Home Address DarvER'SLIC t * <br /> City SrAn 7JP i <br /> I <br /> Owner Halting Address 259 North Wilma Ave � <br /> Mailing Address City Ripon te CA zip 95366 i <br /> i <br /> nwc.inwxrawa. <br /> CoaPoannoN❑ rwmwAL❑ PAyrrR E] Fu,AGERcv❑ ou ea❑ j <br /> FACILITY FILE <br /> FAaznr ID n Eon REE IDX A=Uw IDS # <br /> nwxgng <br /> Is this a NEW Business LOCATION not previously regulated by the ENvIRONmENIAL HEALtH DEPARTMENT? Yes ❑ No <br /> Is this an pGSFING Business LorntlON but a NEW TYPE of regulated Business? yes ❑ No <br /> Busmrss(FAmJSM NAME City of Ripon VWVITF <br /> SmAn 1210 South Vera Ave �V B en,,esSpoehe <br /> 599-2151 <br /> cm Ripon sTAre CA LP 95366 <br /> BOARDDESrJPERVISORDfsrazcr IAGnON CooE KEri Nell <br /> Mailing AddresslFLUFFFRENrrrom F,,&W1yAddress Attention:or CareOf(optloml) <br /> Mailing Address City STATE ZIP <br /> SIC Ctwe APN# Co Urr: <br /> THIRD PARTY BILLING INFO: Comp'eteif Billing Party is different frmn Property Owner or Fadlity Operator,denlifiedabow. <br /> BustREss NAMe Attention:or[are Of(opdortal) j <br /> Mailing Address �OHE <br /> cm STATE ZID I+j <br /> I <br /> a raavrA"eiS for fees and charges OWNER FACILrtyIBUStwss TInRD PARTY BILLING <br /> I,the undentgned Applicant,cenlfy that I am the Oavter,Open or,orAnchodzedAgent of this easiness,and I aelmawtedge that aII PMvRrFkET, <br /> ju a ns,EA'F'aat'es�t7aNsre'andbr/IavxzP[7uAesassochted with fids operation win be bitted to me at the address Identified above as the Arrxn l760➢BfSS for this she. I Rise certify that <br /> all IRformadon provided on this application Is true and earrecl;and that as regulated activities wgi be performed In accordance with all applicable Sen JDAQM Ccnma Ordinance Coda and/or <br /> Standards and STAic and/or btnra.r.Laws and Regulations.As the undenWwd aware,operator,or ageat of the property located at the above fatiWAife eddresy I hereby authorize the release of <br /> any and an results and environmental assessment mfnrmation to SAN JOAQUIN COUNTY ENyetONAIEWEAL HEALTH DEPARTMENT as soon m it Is maaable and at the tame time it is <br /> provided tome or my repreaenmthe. pwryr <br /> APPLICANT NAME p"aa <br /> CI`CY �f Ripan.( `TES soFfK�TSIGNATURE <br /> oa( <br /> RINERS <br /> TrnE �V 3l I C (w'ORkS D I akLTO/L l a QUMD) <br /> A",oved BY Date mReaahg completed By DaN <br /> 29-02-002 April 25,2003 <br />