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A r Sas agdi Caunt�'/ Ener iron al f-lealt 3epar me °:: ' ` <br /> _ .er GREEN FORM <br /> DATE MASTER FILE RECORD INFORMATION '%kMFR" <br /> ' <br /> UNIT IV <br /> -.O <br /> . <br /> OWNER FILE <br /> GiECXIF OWNER CuRRfKRrONFILEWITNEHD <br /> CDMpLETE THEFoLLOa gNGPROPERTY OWNER &FORMA770N: <br /> El <br /> PROPERTY OwNst " PHONE <br /> NAME � � 33 <br /> Fos+ I MI rase <br /> BoS3311FSS NAME /J # SOC SEC/TAX D# - - J <br /> a <br /> Owner Home Address Wo /t J T— o,4� —<Z� DRIVEWs I xENse# /� } <br /> City �o ] <br /> STAT /1 ZIP <br /> ner <br /> OwMailing Address L�j`I— <br /> Mailing Address City r'�•JZl i .�, / StateZip <br /> TYrx or oWN p,5M / O ! (/ <br /> CORPORATION❑ INDr�roALUPARTNERSIiIP❑ FmAoERV❑ orHEa❑ <br /> FACILITY FILE <br /> :'�'�_- ,sF", .a.f r. - I.s--�s::.ukar�,�� �` +t��,�,�:� r�acy��'x'� -� �,��; -�i�`�_ +� -'�`gfL'�►t'V�'���`•�'� ^��"�„sr <br /> I' I AttrrrY.Ii3; ' -, r Ewa CRQS_S <br /> _zr.:..,. ,T, ° '.A ..= ».4 ..;d' ..,. ..Y^--.. :. ;X'. :moo-e•.es,�.ti,?�,. M, 5:'r '-�-jE�a.rw'. <br /> CompLET,THE FOL 10WING BUSINESS FACILITY SITE INFORMATION: <br /> Is tf,Ls a NEw Business LOCATION not previously regulates)ay the ENVIRONMENTAL HEALTH DEPARTMENT? YES L! No ❑ <br /> Is this an ExLmNc Business LocA-aoN but a NEw TYPE Of regulated Business 7 YES ❑ No ❑ <br /> BUS61ESS/FAcmrry/5rrr NAME - - ' <br /> Sm ADDREss SurrE# BUst.R PHONE 3 3 <br /> C;TY /"„ r SPATE ZIP <br /> LocaT-ON:OE' <br /> 1,5cARn of SuPEattrisot:.Dislxicr 1'Viailing Address WDIFFPRENTfrom fadf tyAddress Attention:or Care Of(optional) <br /> Mailing Address City STATE ZIP <br /> ,SICCoDyx �' r asp € IiPfl# s L ,kGOMMENT - ', f� aw <br /> �.ytsf <br /> THIRD PARTY BILLING INFO: Complete if Billing Party is different from Property Owner or Facility Operator identified above. <br /> BUSINESS NAME Attention:orCam Of (opdoaal) <br /> Mailing Address PHONE -- <br /> CITY STATE ZIP <br /> Ar-rnunrrADDRE s for fees and charges WNER FACILITYISUSINESS THIRD PARTY BILLING <br /> BILLING AND COMPLIANCE ACI NOW'LEDGMENT: 1,the undersigned Applicant.Certify that I am the Owner,Operator,or,duthorited.agent of this Business,and I acknowledge that all PERMIT FEES, <br /> PE ALTMS,ENF0RCZVFNr CgARGES andlor HOURLY CIVARGES associated with this operation will be billed to me at the address identified above as the ACCOONTADOR=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 CotIN-rTOrdin nee Codes nedlor <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&MRONNIENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my representative <br /> PLEASE PRI47 <br /> APPLICANT NAME S�l/�D � ytf SIGNATURE <br /> DRIVSE <br /> TITLE f R U PL-�� t./'�" "-'C+1� (PHOCRDPY REQ NtJIRED� 4 'T 7-3 5X-2-3 - <br /> ,PPP wH.�*ky�'�I ���?�'f.DdLEm"'� 8��?„'.':�-..r Ax.. ��,«.;I;�.,r,.,9,,:r�a,s��-sre,.�_� 9 :a;p�e_:�•-�y<d�� :K�`�, .s?T�'�+r�MY:.r.aa.._3'�`.t.�. +, s �...""�c:I <br />