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San Joaquin County Environmental�WwM , yNt ,., <br /> DATE GREEN FORM <br /> " /.2, MASTER FILE RECORD INFORMATION "MFR"r <br /> Cusum sofac <br /> ma FHn Ilei rlwl V OWNER ID! i CASE# --- <br /> 7 UNIT IV <br /> OWNER FILE <br /> COMPLE7FTyEFOLLOWINGPROPERTY_OW E INFORMATION; CNECKIFOWNER CLRREmtroxmxwTNEHD <br /> PROPERTY OWNER NAME PHONE <br /> Frst M1 Lost <br /> ssj— <br /> BUSV4ESS NAME _— <br /> SOC SEC/TAX ID At <br /> Owner Home Address �� �� DRIVER'S LICENSE# <br /> city <br /> `t rpt CJ. STATE C IIP V!1 <br /> Owns Mailing Address <br /> Mailing Address City / <br /> State Z111 <br /> roof rx tlaa.sf.om <br /> CORPORATION❑ INDMDUAL <br /> PARTNERSHIP❑ FED AGENCY❑ OTHER❑ <br /> _ FACILITY FILE <br /> EE�E= <br /> CROSS REF ID# AccouNrID# INv# <br /> LLOKIING 1111 ESS I FACILITY I SITE NFORM ON' <br /> TISthis <br /> a NEW Business LOCATION not previously regulated bV the ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ NoEr <br /> an E)¢srzNG Business LOCATION��but a NEW TYPE of regulated Business? YES ❑ Nos/FAcn rY/Sn-ENAME � JIQ 6 j <br /> SITE ADDRESS I r)C,J Q IY' SUITE# BUSINESS PHONE <br /> (l/(-/ ll r �t� <br /> Cm �iSTAT jjp l� <br /> BOARD OF SUPERVISOR DISrRIR LOCATION CODE KEYS KEY2 <br /> Mailing Address ifOIFFERENTfmm Fad/ityAddress Attention:or Care Of(optional) <br /> Mailing Address City STATE ZIP <br /> --------------- <br /> SIC CODE APN# <br /> COMMENT: <br /> THIRD PARTY BILLING INFO; Complate if Billing Party is different from Property Owner or Facility Operator identified above. <br /> BUSINESS NAME Attention:orCare Of(optional; <br /> Fafff;qAdd— <br /> PHONE <br /> CITY <br /> ({USCI <br /> STATE ZIP <br /> =4 rrurenDRANS for fees and charges OWNER <br /> FACILITY/BUSINESS THIRD PARTY BILLIN <br /> Hrt r rwr.Awn COMPt��Nt-e At'RNOv^rD�y„1: 1.the undersigned Applicant,certifythat I am the 0wno, <br /> Opaarar,or AaYhorized Agmtof this Easiness,and I aclmow ge that all PF2+NT J�'ES, <br /> PENAL7TF_r,EWVRCE1fF1,vT TARCE4 and/or ffOURLr CRARCts associated with this operation will be billed tome at the address identified above-the AQCQ!ZErAnnarcc for this site. I also certify that <br /> aB information provided on this application is true and correct,and that all regulated activities will be performed in accordance with aB applicable SAN JOAQUIN COUNTY Ordinance Coda and/or <br /> Standards and STATE and/or FEDERAL Laws and Regulations. As the undersigned Owner,operator,or agent of the property IO tcd at the above facility/site address,I hereby authorize the release of <br /> any and all results and environmental assessment Wbrmadon to SAN JOAQUIN COUNTY ENyTRONMENTAL HEALTH DEPARTh{{��,,��yy77 as soon as it is available and at the same time it is <br /> provided to me or my representative. I �y <br /> APPLICANT NAME �r i Q� �n �1 `m�� PLEASE PRmi i/yam/L <br /> I/` 111 SIGNATURE <br /> TITLE [ DRIVER'S LICENSE# <br /> �, Gi1�/a l" !x7 (PHOroCOPY REWIRED) <br /> Approveaf By Date Accounting OtTlca Processing Completed By D <br /> 29-02-002 April 25,2003 <br />