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.Y Ih <br /> a� <br /> Sar, �.lr- gVia,:County Environmental Health ROPartment <br /> GREEN FORM <br /> DATE 1� r3 �{ MAAR FILE RECORD INFORMATION ` 'R" <br /> CMencn eRFne CAR FHQ USE ONLY OWNER ID# T9004go(v <br /> CASE# UNIT IV <br /> OWNER FILE !Ny <br /> CompumETHEFOLLOWINGPROPERTY OWNER INFORMATION; t?tFCXIF OWNER CuxaFnrxrorotrtewmt EHD <br /> PROPERTY OWNER NANT PHONE <br /> 1`* First �+ Mt Last �l <br /> BUSINESS NAMJ n <br /> E ! SOC SEC/TAX ID# <br /> Owner Home Address i` DRIVER'S LICENSE# <br /> city STATE ZIP <br /> Owner Mailing Address <br /> Mailing Address City ZtP 5 <br /> TVPF nF AumFg,SHTP �Y3 IJ�h <br /> CORPORATION ElINDrVIDUAL El PARTNERSHIP ElII FED AGENCY❑ OTHER❑ <br /> FACILITY FILE <br /> C t <br /> ��� '� ACCOUNT ID# <br /> F�Xljc <br /> # CROSS REF ID#� <br /> COMPLETE THE f-01 LD <br /> Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? Yrs ❑ No ❑ <br /> Is this an EXISTING Business LOCATION but a NEW TYPE of regulated Business? YES ❑ No C1BUSINESS/FAaLrrY/Sr1E NAME Job r1- <br /> SITE ADDRESS ! SUITE# BUSIN <br /> (fesl� r <br /> CITY C- y STATE/ + ZIP <br /> 1;;--01-`PERVISOR DLS mCi- LOCATION CODE _ KEY/ =" ICEY2 .. <br /> Mailing Address ifDIFFERENTfrvmFacilityAddress Atli /noon:or Care Of(optional) <br /> Mailing Address City !� STATE zip <br /> SIC CODE APN# COMMENT: W- <br /> THIRD PARTY BILLING INFO: Complete if Billing Party is different from Property Owner or1Facility Operator identified above. <br /> BUSINESS NAME Attention:orCare Of (optional) <br /> Mailing Address PO PHONE( �vI ^C (0I ( 1 <br /> CITY / J I{ STATE ��/ ft- ZIP <br /> ASS for fees and charges OWNER FACILITY/BUSINES5 D ARTY BILLING <br /> Rn i Mr_ANn Cf_1MP1 14,Nf F.Af KNOW1.rDrMF.NT; I,the undersigned Applicant,certify that I am the Owner,Operator,or Authori�ed Agent of this Business,and 1 acknowledge that all PERMrT FEES, <br /> PENALTIE4,ENFoxcEmEATCHARGEs and/or HOURLYCHARGES associated with this operation will be billed to me at the address identified above as the gCCQ mXAD2&LCS for this site. I also certify that all <br /> information provided on this application is true and correct; and that all regulated activities will be performed in accordance wvith all applicable SAN JonQ[nN COUNT)(Ordinance Codes and/or <br /> Standards and STATE and/or FEDERAL.Lam and Regulations. As the undersigned owner,operator,or agent of the property located at the above facility/site address,I hereby authorize the release of <br /> any and all results and environmental assessment information to SAN JOAQUtN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is'available and at the same time it is <br /> provided tome or my representative. <br /> PLEASE PRINT SIGNATl3RE <br /> APPLICANT NAME I <br /> 'F- <br /> TITLE DRIVER'S LIENSE# <br /> (PH&OCOP'Y RtOUIRED) <br /> Approved By Date Accounting Office ProcessimJ Completed By Dare O <br /> 29-02-002 April 25,2003 ftp j-" 1 <br /> �1` <br />