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r�°� rmL1 itL: , <br /> San' c� to Caunt3FLEnvlrlanmen#atsFLeait:F p <br /> GREEN FORM <br /> DA-M MASTER FILE RECORD INFORMATION `'tMFR'jr <br /> r OwNrrItTlS:l h CASE Dug <br /> UNIT I <br /> OWNER FILE <br /> COMPLL=TwFOLLOWINGPROPERTY OWNER rNFORMATION: t:HECXZF OWNER CURR£ArnyomRLE wnNEHD <br /> PROPERTY OWNER PONEq�// .-7 �} <br /> NAME y ��i' 1/ f oma + 3 –� 7 �" <br /> First Ml last <br /> BUSINESS NAME ®/TDA/� SOC SEC/TAX D* <br /> Wo <br /> / <br /> Owner Home Address /�O 'f/&-5-yam D� � DRIVER'S LYCENsE# <br /> City /`� fit/Pi fA�_ w ZIT <br /> Owner Mailing Address ��7�._ !J fJ <br /> Mailing Address City v f fJ/ State zip y Q <br /> TYPE OF OWNERSHIPv�- <br /> CORPORATION❑ IND IDUALV PARTNERSHIP D FED AGENCY OTHER <br /> FACILITY FILE -- <br /> .FACILITY Ix)# -! Q CRoss'Rr�ID of w AccouNr ID# ' ra j <br /> COMPlErz-77YEFOLLOW-0 G BUSINESS / FACILITY SITE INFORMATION: s� <br /> Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES �i No <br /> Is this an EXLSTING Business LocATloN but a NEw TYPE of regulated Business? YES C1 No fJ <br /> BUSINESS/FACIIm/SITE NAME <br /> F—L 4U to Ait�'PA-V rL <br /> .$ITP AOD1tE55 � � I J-J SUITE# BUSINESS PR— -3; 3 <br /> 3 <br /> - -2 s <br /> 5;0V-,t-;-f 'r k 3 <br /> Crnr /� ' ,,-' �� STATE ZIP q / <br /> h BOARD OF SUMVISOiLAISYRdCT toc�TloN£ooe .. I. Keti � - <br /> ?Wailing Address ifO.IFFERENTfivmfa6lityAddress Attention:or Care Of(optional) <br /> Mailing Address City STATE Zip <br /> SIC CODE APN# COMMENT.:- <br /> THIRD PARTY BILLING INFO: Complete if Billing Party is ditlrerentfrom Property Owner or Facility Operator identified above. <br /> BUSINESS NAME Attention:or Care Of (optional) <br /> Mailing Address PHONE <br /> CITY STATE ZIP <br /> Accounff-AyQaEss for fees and charges ER FACILITY/sUSINESS THIRD PARTY BILLING <br /> BILLING AND COMPLIANCE ACKNOWI.EDgmENT: 1,the undersigned Applicant,certify that I am the Owner,Operator,or Authorized Agent of this Business,and I acknowledge that all PERMIT F=, <br /> PEN,mFS,F_NFVRCeMF-'7'CHARGES and/or 1JOUxL>'CHARARGEY associated with this operation will be billed to me at the address identified above as the ACCOUNTALDRFSs 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 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 all results and environmental assessment information to SAN.JOAQUIN COUNTY ENVIRONMENTAL HEAI,T}I DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my representative. <br /> PLEASE PRutT <br /> APPLICANT NAME S�l26.0 �6A�J 'j Jw .f�f ], SIGNATURE <br /> TITLE ��� /h y-�/ D� . I4�L� 'I.0/LJ DRIVER'S LICENSE# y J� <br /> A (PHOTOCOPY REQUIRED) 73„�L�d-3 <br /> t Approved BY -; Date ACCountirtg Office Prtxessing Carnpleked�y Date <br /> h <br /> T <br />