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* ECOWED <br /> SAA99�p; pp <br /> San Joaquin County Environmental Health Gtr _rtmentOCT GREEN ORM <br /> SATE 0— 3—(�� MASTER FILE RECORD INFORMATION "MFR" FN`,/IRONNIEN TT HEALTH <br /> SHAOEDARFASFOREHOUSEONLY OWNER ON Q I I� I CASE# �DER"`1jWff E;V <br /> ll /OWNER FILE <br /> CO#rpLETETHEFOLltonwaPROPERTY <br /> COWNER/NFORMill7lo CHECKIFOWNER CORnnWRH <br /> ENrONRLEEHDEd <br /> /J <br /> PRoperry OYMERNAME O `+ PHONE (7q i <br /> First v 1 MI Last <br /> BUSINESS NAMECt v \ ' I� y` SOCSEC/TAXID# <br /> Owner Home Address `? ""JJ l,�� V I '06q-0'j RIVERS LICENSE# <br /> City a STATE ( LP J <br /> Owner Mailing Address - n <br /> p WC <br /> Mailing Address City State ZIP <br /> CORPORATION❑ INDIVIDUAL❑ PARTNERSHIP❑ FED AGENCY❑ G OTHER <br /> FACILITY FILE <br /> FACILITY ID# da CROSSREF ID# ACCOUNTID# ��-L �Q'Jl INV# <br /> CommETETHEFOLLOwmi;BUSINESS/FACILITY/SITE INFORM47/0N.- <br /> Is this a NEIN Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPT.? YES ❑ No 54 <br /> Is this an EXISTING Business LOCATION but a NEW TYPE Of regulated Business? ONO <br /> YES ❑ No <br /> BUSINEsWFACILRY/ — 50 O1 / `Q <br /> SITE AODR BUIfE# BUSINESS PHONE <br /> � n/ t <br /> Cm 'sL-J STATE /' LP IyN�L <br /> BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEY1 KEY2 L <br /> Mailing Address it'DIFFEREATITOO FmIlitysiddress Attention:or Care Of(opUesna/J <br /> Mailing Address City STATE ZIP <br /> SIC CODE APN# COMMENT: <br /> THIRD PARTY BILLING INFO: Complete ifBillingg Party is <br /> different from Property Owner or Facility Operator ide'1n�fifille�d`above. \�j � <br /> BUSINESSNAME jI 1�^i l V Attention:orCare Of(oublont V/v v ' " " <br /> Mailing Address IU/I` l D PHONE ( J C O� <br /> CITY t-�I_` 1=u LA „f$, (J STATE his J <br /> Afor fees and Charges OWNER FACILITY/BUSINESS THIRD PARTY BILLING <br /> BILLING AND COMPLIANCE ACKNOwLEDGMF]l': 1,the undersigned Applicant,certify that I am the Owner,Operator,Or Authorized Agent of this Business,and 1 acknowledge that all PERMITFEes, <br /> F£NALTms,ENFORCEMENT CHARGES and/or HOLRLICNAROEB associated with this operation will be billed to me at the address identified above as the ACCOUNTADOR£SS for this site. 1 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 I :IDFRAL Laws and Regulations. As the undersigned owner,operator,or agent of the properly located at the above facility/site address,l hereby authorize the release of <br /> acv and all results and environmental assessment information to SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as' is available and at the so time it is <br /> provided to me or my representative. <br /> APPLICANT NAME V S--Au-2 { '<PLEASGPRINT SIGNATURE r� <br /> TITLE fin-_ `O / �Y(?�cc� (JCA eyq> -) DRIVER'S LICENSE# Tl 'C� 4 L y <br /> Jett V (PHOTOCOPYREQUIRED) �f J 1 ✓A <br /> Approved By Date Acceunang Office Procesairlg Completed By Data /0 4 <br /> 0/ <br /> 29-02 10/12/07 ^\t � ��^ =F 1 �� ��\ MASTER FILE RECORD-GREEN <br />