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SanJ1 quin County Environmental Health Dee artment <br /> GREEN FORM <br /> DATE MASTER FILE RECORD INFORMATION `TMFR" <br /> SHADED eu Fac cng Pun nccnu,r OWNERID# CASE# UNIT IV <br /> OWNER FILE <br /> COMPLETE TNEFOLLOWINGPROPERTY OWNER IN(FORMWZON. CNECIIlP OWNER CVRRExnvONlr-n£WnH EHD <br /> PROPERTY OWNER NAME CA ec5�" Q I f1 `/� -,eulA <br /> I/�l' PNONE <br /> l•Flat MI /� U•1 1 Lost <br /> '1 <br /> BUSINESS NAME t/ ^ e ,etiev II SOCSEc/Tm ID# <br /> Owner Home Address c ' 1 0-7 VryI 'WV r .l DRWER'S LICENSE# <br /> CRY l/ 1 STATE i-/1 Z[P <br /> U7Owner Mailing Address <br /> Ga4 ULe <br /> Mailing Address City a ^^ a a V p State ZIP <br /> TW ECIWNFRqHT <br /> CORPORATION❑ INDMDUAL0 PARTNERSHIP❑ FED AGENCY❑ OTHER❑ <br /> FACILITY FILE <br /> FAci m ID# CROss REP ID# ACCOUNT ID# INV# <br /> OMPLE7E77iEFOLLOWING BUSINESS I FACILITY I SITE DyFoRmArzoN,' <br /> Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT7 YEs ❑ No ❑ <br /> Is this an E%ISTING Business LOCATION but a NEW TYPE of regulated Business? YEE ❑ No ❑ <br /> BUSINESS/FAmm/SIZE NAME ern i�' 6evit e, <br /> $READDRESS 1/`7 G w NO-7 17 I L ` rloo "I Start# BUSINESS <br /> CRY � STATEGn- ZIP S ;�/S— <br /> BOARD <br /> lS' ✓/ <br /> BOARD OP SUPERV60R DI5TRICT I=T10N CODE KEYS REY2 <br /> Mailing Address ifDIFFERENTfrom FadlityAddresr Attention:or Care Of(optional) <br /> Mailing Address City STATE ZIP <br /> SIC CODE APN# COMMENT: <br /> THIRD PARTY BILLING INFO: COIN (ate if Billing Party is different from Property Owner or Facility Operator identified above. <br /> BUSINESS NAME Attention:cm-Cam Of (optional) <br /> va✓1�� FnVi/r1�Mp <br /> Falling Address (` �/� `11 PHONE /� /`�� <br /> Cm 7 / I—r 1 v} STATE C /y 7]P l 1`�� <br /> for fees and charges w OWNER FACILITY/BUSINESS T(THIRD PARTYBILLING <br /> Bn.r mw ANn r AWT IANE Aca Ow,F.DGMaNT: 1,the undersigned Applicant,certify that I.the Owner,Operator,or AmharizedAgem of this Busio all-P£RARl'FEES, <br /> PENALRES,EN RCEN£NTCEIARG£S and/or ROI/RLYCRARGES associated with this operation will be billed tome at the address identified above as the ACCOLATADDRFCC for this sit. I 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 J0AQ111N COUNTY Ordinance Codes and/or <br /> Standards and STATE and/or FEDERAL Laws 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 aB results and environmental assessment information to SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as't is available end At the some time it u <br /> provided to me or my represen�j Wiz <br /> APPLICANT NAME 1"1rlG l� M Ill/✓ r/IY 1 EPRINT SIGNATURE �✓ <br /> TITLE Qr�ec� (zf ol�� DRIVER'S LICENSE# <br /> (PHIVEWS LICEREOUIRNSE <br /> APPmvad By Data Accounting Office Processing Completed By Date <br /> 29-02-002 April 25,2003 <br />