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14W <br /> N <br /> GREEN FORM <br /> DATE "MFR" <br /> MASTER FILE RECI INFORMATION <br /> UNIT IV <br /> OWNER FILE CHECKIF OWNER CURRENTLY ON FILE WITH,EHD <br /> COMPLETE rHEFOLLOWING PROPERTY 0 TION: <br /> SOL BE.IT-10. <br /> 0"'d -C <br /> PROPERTY Serf <br /> PHONE <br /> OWNER NAME <br /> Fire so hel <br /> BUSINESS NAME SOL SEC IT"11)A <br /> 1916)q LjesAr- irwn skirrj %-42 <br /> DRIVER'S LICENSE III <br /> Diviner Home Address 4V—ro*.2 5A-evt 5i't+e <br /> city a"jer STATE zip F03.3 7 <br /> Owner Mailing Addr... san,# 4s Aizw <br /> Mailing Address City State' Zip <br /> =A71:14 INDIVIDUAL❑ PARTNERSHIP❑ .FED AGENCY 0 OTHER 0 <br /> FArill Ixy Fill F <br /> ................................. <br /> in, <br /> ........ <br /> �—p <br /> COMPLETE THEFOLLowiNG BUSINESS i FACILITY I SITE INFORMATION; <br /> Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? ya; ❑ No <br /> lathisan EXISTING Business LOCATION bUta NEWTYPE of regulated Business? YES 0 NO 19 <br /> BUSINESs1FAcILITYISITE NAME <br /> SITE ADDRESS SUITEt BUSINESS PHONE <br /> gas /V gra a )-bj - )IbOlts <br /> Cite STATE zip <br /> 00ARs(W$1 P VISOR I j f OCATIQht o tE I.:Kryl <br /> Mailing Address iiDIFFERENT-fron,FavilifyAddress, Attention:or EST.Of(optional) <br /> e 0, '90% <br /> Mailing Address City S,J <br /> STATEC 4 zip a S-- <br /> ......... ... <br /> . ...... FAPNO <br /> THIRD PARTY BILLING INFO: Coinpiete if Billing Party is different from Property Owner or Facility Operator identified <br /> above. <br /> BUSINESS NAMEAttention:or Care Of (OPHOnall) <br /> '42';�-% 1016,q Wabliarn, S&'-j;Lq )3r;M.., Pndler- <br /> Mailing Address P 0. 1 PHONE ?6S-- Y9Z-1?.31 <br /> CITY cl�e5 Mane STATE—TA--" Zip 'Y-7 11 (a <br /> ACCOUNTADDRESS for fees and charges OWNER FACILITY[BUSINESS THIRD PARTY BILLING <br /> RTT,T,TNG ANp CompLIANCE ACKNOycLIEDGMENT: 1,the undersigned Applicant,certify that I am the Owner,Operator,or Authorized Agent of this Business,and I acknowledge that all PERWT <br /> FE,,,,pE,,,,,,,,ENTCReEM1 TCLEteGRe and/or HOURLY CHEI associated with this operation will be billed to me at the address identified above as the irrouwArmir a for this site. I also <br /> certify that all information provided an this application is We and correct;and that all regulated activities will be performed in accordance with all applicable SAN JOAQUIN COUNTY Ordinance <br /> Codes med/.w Standards and STATE and/or FEDERAL,Laws and Regulations. d ' d al,or agent of the property located at the above facility/site address,I hereby <br /> authorm the release of any and all results and environmental assessment mfanr�AshhT RM —unNMENTAL ITEALTH DEPARTMENT as soon as it is available and <br /> at the same time it is provided to me or my representative. <br /> PLEASE PRINT <br /> APPLICANT NAME SIGNATURE <br /> DRIVER'S LICENSE 0 <br /> TITLE e- iPHQTnP.QPY RFOijigFnl <br />