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qulnCountEnir" , <br /> Y enfi I :epa r Leh <br /> DATE � � MASTER FILE RECORD NF GREEN FORM <br /> I ORMATION ` MFR" <br /> F'n n <br /> OWNERID# (] CASE# <br /> UNIT IV <br /> OWNER FILE <br /> COMPLETE THE FOLLOWING PROPERTY OWNER INFORMATION; CHECKIF OWNER CuRRENTtroNF1LEWITHEHD ❑ <br /> PROPERTY OWNER <br /> NAME / <br /> PHONE <br /> First MI <br /> last <br /> BUSINESS NAME <br /> r r el e 4 ,ll�rP T' f�._.. SOC SEC/TAX ID# <br /> Owner Home Address <br /> VI r1GAq/ Ap v DRIVER'S LICENSE# <br /> city <br /> STATE �' ` <br /> Owner Mailing Address OrT / <br /> Mailing Address City <br /> State Zip <br /> TYPE or nWNFR^^CHTP ^ �7 <br /> r'llp Dhp ATTr1N I.�I TNr1TVfr111G1 I..I DepT1JFDCHiD F1 ^ <br /> FFn Ar—F I_.I ATHFD <br /> All'-11 IXX Fill F <br /> yam.��A,'! <br /> .FACILITY ID# :i ,.„wry`sa CROSS REF ID# ACCOUNT ID# t t °'"COMPLETETHFF INV# <br /> _a A <br /> T <br /> Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ No f. <br /> Is this an EXISTING Business LOCATION but a NEW TYPE of regulated Business? YES ❑ No <br /> BUSINESS/FACILITY/SITE NAME <br /> SITE ADDRESS <br /> /•Z.2 �. � ��Q � BUSINESS PHONE <br /> S� ��� SUITE# BUS <br /> crry <br /> 7/ v G,ff 70 -xr STATE uP p <br /> .xx <br /> [`rLorwtON I' r '�, �� ,... w$, „ knyrv• a .r S`>I <br /> BOARD OF SLIPERVI50R DISTRiCf,- � , M <br /> Mailing Address if DIFFERENT from foci/ityAddress Attention:or Care Of(optional) <br /> Mailing Address City STATE ZIP <br /> APN# <br /> THIRD PARTY BILLING INFO: Complete if Billing Party is different from Property Owner orFaciIity Operator identified above. <br /> BUSINESS NAME <br /> z�se Attention:or Care Of (option 0 <br /> !/l d'L�'�/M tLv /4/ �" V 7Q r <br /> F�;�7 <br /> PHONE <br /> Cm ,t% STATE zip I ./7•,,(/ <br /> ACCOL I Annvccc for fees and charges OWNER <br /> FACILITY/BUSINESS THIRD PARTY BILLING <br /> BILLING AND Cf)NIP't INCE +CENrnn EDGNIENT: 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 /> PENALTIES,ENFORCEMENT CHARGES and/or lIOURLYCHARGES associated with this operation will be billed tome at the address identified above as the ACCnnwrAnnREce for this site. 1 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 SAN JOAQUIN COUNTY Ordinance Coles amt/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 hereby authorize the releas:-of <br /> any and all results and environmental assessment information to SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time itis <br /> provided to me or my representative. <br /> PLEASE PRINT <br /> APPLICANT NAME (5�I°y �/G f SIGNATURE <br /> K sL� �diro� ��••Ya. ; <br /> TITLE /� •— <br /> L/ rPf/ P t,�7— DRIVER'S LICENSE# <br /> (PHOTOCOPY REQUIRED) <br /> LApproved By; Date <br /> Accounting Office Processing Completed By . ', r„ Date2 �E` ' <br />