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Sancin CoEFttiy E�tvironlnenial I IeatfrUienx <br /> GREEN FORM <br /> DATE �_tg._ az MASTER FILE RECORD INFORMATION "MFR" <br /> gWPER l #: / .. 6asfi# UNIT IV <br /> n <br /> OWNER FILE <br /> COMPLETE THEFOLLOW/NG PROPERTY OWNER INFORMATION: CHEcKIF OWNER CuRRENTLYON FILE WITH EHD <br /> PROPERTY PHONE <br /> OWNER NAME <br /> Fin MI (-1 <br /> BUSINESS NAME SOC SEC 1 TAX ID# <br /> i Rem:( OISA Wes>br. �,� SQYJ ;�e <br /> Owner Home Address y rt.2 (� u I Sfe,' S�yQe f SU t.F e 7 aJ� DRIVER'S LICENSE# <br /> City ✓M J<� �a STATE ZIP �Q,37 <br /> Owner Mailing Address SQ 1'nfl S / o f <br /> Mailing Address City lJ state Zip <br /> CORPORATION INDIVIDUAArL❑ PARTNERSHIP❑ FED AGENCY❑ OTHER❑ <br /> RAN-.REI^H}.:t ACA>1slNT fUik + 'c ail'[i.. IILv# .:'. <br /> COMPLETE THEFOLLOW/NG BUSINESS I FACILITY t SITE NFORMATION: yAA, <br /> Is this a New Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ No I" <br /> Isthisan EXISTING Business LOCATION but NEw TYPE of regulated Business? YES ❑ No <br /> BUSINESSIFACILITTISITE NAME <br /> Wesi'err, Fir.. See J'ce <br /> SITE ADDRESS SUITE# BUSINESS PHONE <br /> 805' N. g'aada - sf7- �boo <br /> CITY STATE ZIP <br /> j k -tor [ < N <br /> ..1;7t3Jtlt#4Ik` SiVt 1 �..fYCATIGhfS?LL13E .R.. �::.:1 .: E KEr3 II <br /> Mailing Address if DIFFERENT from Facility Address Attention:or Care Of(optional) <br /> e a Bo)( .5-)88 <br /> TEC n, ZIP <br /> Mailing Address City c.f_ L LLy„ STA4S.16,S <br /> BLR F, �J*P/ND�"Fr0 COMMENF' <br /> THIRD PARTY BILLING INFO: Complete if Billing Party is different from Property Owner or Facility Operator ldentdied <br /> above. <br /> BUSINESS NAME Attention:or Care Of (optional) <br /> rau.y f�R1w..l OQ✓"� W25 der rr✓An .SQ rJ;LQ ria+. �,��2✓ <br /> Mailing Address P Q PHONE <br /> cin ('-!i e5'(' L cf a ehtr- STATE TN ZIP y 7 9 4 b <br /> ACCOUNTADORESS for fees and charges OWNER FACILITY/BUSINESS THIRD PARTY BILLING <br /> BILLING COMFLIANCx ACXNOVT YDGMENT: I,the undersigned Applicant,certify that I am the Owner,Operator,or Authorized Agent of this Business,and I acknowledge that all PEK197' <br /> FSEs,PENALTTES,ENRORCFbIENTCEARcm and/or ROMMYCKARGES associated with this operation will be billed to most the address identified above as the ArcauNT Annavice for this site. I also <br /> certify that all information provided on this application Is true and correct;and that all reoulat<d=divides will be performed in accordance with all applicable SAN JOAQUIN COUNTY Ordinance <br /> Codes and/or Standards and STATE and/or FILDRRAE Laws r- '' owner,operator,or agent of the property located at the shave facilitylsite address.I hereby <br /> authorize the release of any and all results and environments LIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and <br /> at the same OmeiIt H rovided to me or my representative. Pp—D�10O�p co <br /> 13 IC // s.i Lo <br /> Q ? PLEASE PRINT <br /> APPLICANT NAME �.7y�c� (� ���e✓ SIGNATURE <br /> DRIVER'S LICENSE# <br /> TITLE EN U-/cN rng'+*4 <br /> <, 5.: I: :,max:. <br /> .. ..: <br />