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` San Aquin County Environmental Health Department <br /> rr'' GREEN FORM <br /> DATE c v� MASTER FILE RECORD INFORMATION "MFRtr <br /> Qiumm ADFAs MR awn oec Duty OWNERID# d4613 /ac�-Un CASE# UNIT IV <br /> OWNER FILE <br /> IY/ECK£F OWNER CORRENIzrnrvPUE waH EHD El <br /> CommETFTNEFOLLOWINGPROPERTY OWNER INFORMATION: <br /> PROPERTY OWNER NAME Pt10NE <br /> First I M/ Last <br /> BDszNEss NAME 0\ C—A 1 _ C. C, SDCSEC/TAXID# <br /> Owner Home Address DRIVER'S LICENSE# <br /> ZJ2 G <br /> City A.�J^ ^ SPATE "' 95337 <br /> Owner Mailing Addles <br /> Mailing Address City State Zip <br /> IVPF ncnwuagSHlp _ r/�[ <br /> 1 �TION❑ INDIVmW1L❑ PARTNERSHIP❑ FED AGENCY❑ <br /> v FACILITY FILE <br /> +V! FACILITY ID# I b'LQ CROSS REF ID# ACCOUNT ID# Sy3 INV# <br /> COMPLETE WFOLL014TNO BUSINESS I FACILITY I SITE rNFORMA770N.' <br /> Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? Yes ❑ No <br /> IS this an EXISTING Business LOCATION but a NEW TYPE Of regulated Business? Yes ❑ No <br /> BBSRISSS/FAmm/SITE NAME 1 G <br /> SITE ADORES G$�,�Qc CA.T I SUIIE# BUSINESS PHONE <br /> Dm rrY, kcc STATf,A zus 95337 <br /> BOARD OF SUPERVSOIt DISTRICr LOCATION CODE KEYS KEY2 <br /> Mailing Address YDIRERENTTrorrr FadlityAddress Attention:or Care Of(ophiawl) <br /> —97 In <br /> Mailing Address City <br /> SIAMEC� Zip <br /> �C-ll�C r1 <br /> SIC CODE APN# COMMEM: <br /> THIRD PARTY BILLING INFO: Completed Billing Party is different fromProperty Owner oi-Fadftv Operator iderti.9edabove. <br /> BUSINESSNAME Attention:or Care Of (optional) <br /> �z cue <br /> Mailing Address q _ PHo` l <br /> CITY STATE ZIP <br /> 1�c��eti�, � l r� 9vI 4ti 9 <br /> AccaLmizAaagga for fees and Dharges OWNER FACILITY/BUSINESS THIRD PARTY BILLING <br /> •n•• FnGMFNT: [,the undersigned ApplicanR certify that I am the C)mor,,npm m,,or Authorized Ageut of this Business,and 1 acknowledge that RU PERM/TFE£S, <br /> PENALTIES,ENMO EMENTCHA Es and/or RouaLYCNA a associated with this operation will be billed to me at the address identified above As the APYnrMTADDaEIg for this site. 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 JOAQUIN COUNTY Ordinance Codes and/or <br /> Standards and STATE andlor 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 all results and environmental assamoreat information to SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br /> provided W me or my representative <br /> n� c ypyEILSE PQM SIGNATURE NAME � <br /> ^c�yt <br /> TITLE / DRIVER'S LICENSE# <br /> G Ka 6L G rL (PHOTOCOPY REOUIRED) <br /> APProYed BY Dabs Attaunting Office Processing Completed BY I Data <br /> 29-02-002 Apn125,2003 <br />