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San Joaquin County Olblic Health Services Environmeo Health Division <br /> GREEN FORM <br /> DATE F <br /> /-ZS•6y MASTER FILE RECORD INFORMATION "MFR" <br /> SHADED AREAS FOR EHD lSE ON LY OWNER ID# CASE# UNIT IV <br /> OWNER FILE <br /> ❑COMPLETE THE FOL LOW/NGPROPERTY OWNER INFORMATION; CHECKIF OWNER CURRENTLYONFILEWITHEHD <br /> PROPERTY OWNER � / JPHONE /J� I'��• •�, <br /> NAME !/r►'� `y 5 / l![� <br /> First Ml last <br /> BUSINESS NAME �` 5 <br /> rex a, �`I✓tm(f/Y1 t I/uCSEC/TAX ID#C4l� t �Yla C�Yn raarj <br /> DRIVER'S LICENSE# <br /> Owner Home AddressE /�,t <br /> /i STATE ZIP <br /> Clty ) f �/.. <br /> Owner Mailing Address !I fl <br /> Mailing Address City $tate C i ZlpW`J?3—07 Z 5 <br /> NNFR�S,H/IP <br /> CORPORATION U ING FED AGENCY E] OTHER❑ <br /> LE <br /> FACILITY ID# OUNT ID# INV# <br /> COMPLETE THE FOL LON <br /> YES ❑ No Ge <br /> Is this a NEW Business LOCATb <br /> YES ❑ No <br /> Is this an EXISTING Business LC — <br /> BUSINESS/FACILITY/SITE NAME Ir`�r� �r'1C Gl La e(ro <br /> SUITE# BUSINESS PHONE <br /> SITE ADDRESS <br /> CITY �- ESTATE ZIP <br /> IIBOARD OF SUPERVISOR DISTRICT _--ON CODE I I KEY') I _ ( KEY2 ;?�;a, OR— <br /> BOARD <br /> Mailing Address if 0lFFERENT from Facility Address <br /> Attention:or Care Of(optional) <br /> STATE ZIP <br /> Mailing Address City <br /> SIC CODE APN# COMMENT: <br /> THIRD PARTY BILLING INFO: Complete if Billing Party is different from Property Owner orFacility Operator identified above. <br /> BUSINESS NAME Attention:orCare Of (optional) <br /> i�va1-0 IC <br /> Mailing Address ^� k vl hnIICQ/t O �+ vX �1) I Z-' PHONE jt✓l T\ 41_ J�L( <br /> CITY C ��^^.T`^ ^ TATE ZIP 04-5Y3 <br /> IYA- <br /> ACcouNTAooREss for fees and charges OWNER FACILITY/BUSINESS THIRD PARTY BILLING 1 <br /> aIIt ISG AND COMPI IANCF ACKNOw1.F.DGNIENT: 1,the undersigned Applicant,certify that 1 am the Owner,Operator,or Authorized Agent of this Business,and I acknowledge that all PERMIT FEES, <br /> pt..,V,ILTlES,ENFORCEMENT CHARGES and/or HOURLY Ce.AROES associated with this operation will be billed to me at the address identified above as the AccoE'.vTADORE'ss for this site. I also certify that all <br /> information provided on this application is true and correct;and that all regulated activities will be performed in accordance with all applicable SAV JO.AQCIV 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 herebv authorize the release of <br /> any and all results and environmental assessment information to SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DIVISION as soon as' 's available and at the same 'me-it is provided to <br /> me or my representative. <br /> PLEASE PRINT <br /> { SIGNATURE'` <br /> APPLICANT NAME <br /> �o k �A' �1) c)\j k6t <br /> M1 n� DRIVER'S LI SE# <br /> TITLE �1'n�, �(C1C �Gll'n �1 Ll r 1L1 C C r (PHOTOCOPY EQUIRED) <br /> Approved By Date Accounting Office Processing Completed By Date <br />