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T4 <br /> San Joaquin County Environmental Health Department <br /> i GREEN FORM <br /> _ <br /> DATE -2,$'- 2WL MASTER FILE RECORD INFORMATION "MFR" <br /> '# UNIT IV <br /> GMRnLA eaFAC FM FHtI[KF f1N1 Y ����� s -� <br /> I <br /> OWNER FILE <br /> COMPLETE THEFOLLOWYNGPROPERTY OWNER INFORMATION; �rOWNER CuRReNYLraNrvFwmf E H D <br /> PROPERTYOWNEIeNAME 'I PHONE G/! _7 7&_ <br /> First M1 last <br /> BUS0NESS NAME i SOC SEC/TAX ID# <br /> Owner Home Address f ` S 1 1. u t 1-n �( � DRrVER s LICENSE It <br /> w J `f' Tim v v d <br /> STATE 1y ` <br /> Gty `' I 9 0p� 1 <br /> li <br /> Owner Mailing Address I <br /> Mailing Address City Zip <br /> IYOF nF AunuF� .i <br /> CORPORATION M INDIYIDuAL❑ PARTNERSHIP 0 FED AGENCY E] OTHER <br /> EI <br /> FACILITY FILE <br /> FaCZLrrYID# M CROSSRTID# ACCouHTID# <br /> ,� <br /> COMPIF7F THE LL M ON• <br /> Is this a NEw Business LocAnoN not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENTS YES © No <br /> Is this an EIasTING Business LowioN but a New TYPE of regulated Business? YES J' No l] <br /> BUSINESS/FAaLrTY/SDE NAME l <br /> SITE ADDITsss 1 -!zoo SUITE# BUSINESS PHONE 91� y f 9i/3 <br /> CITY G �� j STATtr), Z11' <br /> Mailing Address WDIFFERENThmm Fad1RyAdkffvm Attention:or Care Of(opbbnal) <br /> �i <br /> Mailing Address City j STATE ZIP <br /> E-i �� 1�._ <br /> + .. . <br /> THIRD PARTY BILLING INFO; Complete if Billing Party is different from Property Owner orFkiiity Operator idenffried above. <br /> Busnam NAME Attention:or Care Of (optional) <br /> Mailing Address I PHONE <br /> CITY �I STATE 7]P <br /> Acrnrrur ADDR for fees and charges OWNER FACILITY/BUSINESS THIRD PARTY BILLING <br /> HILTING Arm f OMP]IANC±A t'avrnvl.enrMENT: I,the undersigned Applicant,certify that I am the Owner,Operator,or Authorized agent of this Business,and I acknowledge that all PFRWTFFES, <br /> PENALIZES,ENF4RC7?MENI'CHARGES andlor HOUNLYC1Gll2GlESassociated with this operation will be billed to me at the address identified above as the dCl;;4.tliYLBl]pSi~SS 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 applica a SAN dOAQUIN 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 it lh bov aeility/site address,I hereby authorize the release of <br /> any and all results and environmental assessment information t0 SAN JOAQUIN COUNTY ENVIRONMENTAL I�ALT[I DEPAki soon as it is availa a and at the same time it is <br /> provided to me or my representative. <br /> APPLICANTNAME M I�Gr/' PLE�tsEPaDvrt SIGNATURE <br /> ' uM� �Or Q�,mer C. 11tl r14� ��O �n VI rna.Ir•e x� D�Tn00Pr r t aED) I Z 0 <br /> Ap.-.d aY Date Acmttntirg Office Prooessiltg Completed aY , Dace <br /> 29-02-002 Aril 25,2003 <br /> April V �GNFIOENTIAL <br /> _ <br />