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0429/2005 09:27 CLAYTON GROUP i 12094683433 NO.319 1?02 <br /> San J�quln County Environmental Health 9iartment <br /> n GREEN FORM <br /> DATE a Z��`fS MASTER FILE RECORD INFORMATION MFR <br /> OMMID# cAsii UNIT IV <br /> OtIMER FILE <br /> COA�PUT£Trd£FnuowmrePROPE OWNS FoaAwnoAr' LWeeR.r OWNER cuAReamvoNFnetmN WDPROPE¢nowxea HANE t v1 F Lwi7'7G(�C PHONE Z S <br /> Foal A9 fast <br /> Csaysess Nose bac sec(TAxID x <br /> owrerFlAme Atldlew � 1 � /O �f. �[ �e Duvalsu�# - <br /> CRY Ara / CA� $TATE [tSo <br /> Oxem MaBNlg Adds® �� s e <br /> �rL t� <br /> KRA[%Address City S -p C -�_ -- Steen AP L f Zc^7- <br /> gRPexA1]pll❑ INmYIOIIAI IJ PARrIla6NtP4-I FEU AGENCY❑ DINER <br /> FACILITY FILE <br /> FA13UTT IDA CROSS REFID# ACCOUNTIO A Ixr# <br /> IS Nis a flew Beeine es LOCATIUN not Previously regulated W the ENVIRONMENTAL HFALTn DEPARTMENT? res ❑ No Ev/ <br /> Is Nis pOSRN4 etwinets t.Dunon but a NEW Tree orrequiated Buainexs? vis Cl NO f9� <br /> xusaxess/PAatm/gt1E NANr <br /> sm sum# BYSIxP.fitPNmB <br /> cm SYME zip <br /> EoWDOP6UPFirdEAa DtSTREST I,aCRTION Cace Krf1 Kev! <br /> Mailing Address d'OTFFCRslNThamFvrAWyAddr Attention:or Care Of(oprbadQ <br /> Mailing Address City 'STAT% IIP <br /> SIC OPO% APN# commem <br /> THIRD PARTtf ROLLtNo(flF®t Complete if Billing Party is different from Property Owner of facility Operator Idenb*d above, <br /> Buaxrss HANE � Attention:orCam Or (opumHg- — <br /> irav 5•e.-Wf�� e� <br /> MaDllp Addy611,100 <br /> A'"""""'"^"OOGe for Idea and charges OWNER FACILIIYIBUSINEssMD PARTY BIL1iNG . <br /> rm,,,a-.N.rupy,,.nrx 9fb"ii^t'rr"'r"^'^'*' I,lne xndmlgned nPPliwnL eertlN thatlam tie�.we,Gpramr,or Aadm4dAgant oftldc Dudrnm,old Iaelmowkdge that as FfeReal"FePs, <br /> PZW1%S,FA�CfURCEB andlor HOWYCIVRC6s afilonoled wish this opcntiunwill he billed to not 0 the.ddreaa identified abaft w the nLY1'tTW4paRM for ask aha IAhoes lrythat <br /> all hlformallon prmided on this application lc tree and mrrm;and Ibal9e regtirold nalviUes will he pertbnoed In omardance wf i oil applicable WJOAQ00s Colmfr Ordlname Codes and/or <br /> Smndarda.d STwrn and/or 171109M,Law.and R,61.Lena. Ax the andmignd nano,opasmr,or ogenl of Ns proporiy to rotd at dra obw<faelPryhNe adJrrn,I hereby arMor4.do reka.e of <br /> any eM an rotate,and glvlronmenul asresemont Infermallon to SAN TOAQL4N COU-WY ENVIRONMENTAL ATALTI-1OKPARTMEfn as anon as Ills aniNUle and M Cbc lame alk It k <br /> prmldd b me or MY ropm2al itux— T/0-r <br /> APPUCANT NAME ! �f / 9CONAtURE�—� <br /> TITLE f J DRIVFRrG LtCENSF# <br /> B-J?,jl- G! (PHGixOPr ReoumePl - - - <br /> Appnved BY Dote Iw7'rho wee Proeadnx completed B% Oah <br /> 29-01.002 Apn125.2003 <br />