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M, San . uin County Environmental.Heal partrnent . <br /> GREEN FORM <br /> DATE �. MASTER FILE RECORD INFORMATION "MFR" <br /> ,w cunl«n.r owN�ItID - # 3 } UNIT IV <br /> << <br /> OWNER FILE <br /> COMPLETE THE FOLLOW <br /> ING PROPERTY OWNER INFORMATION; CHECKIF OWNER CURREKTLYON FILE WITH EHD El <br /> PROPERTY OWNER a/cPHONE 1,5; - a�� • ��� <br /> NAME <br /> First MI last <br /> BUSINESS NAME0 A O� � SOC SEC/TAX ID# <br /> Owner Home Address DRIVER'S LICENSE# <br /> city STATE ZIP <br /> Owner Mailing Address / SA I"" C <br /> Mailing Address City v O c Z/& - State Zip Sr <br /> TVPF t1F nWNFPCHTP V <br /> rn.P PATTr1N❑ TNf1T nlfA1 ❑ CAPTNFPCHTD❑ FFn ArPN ❑ nTHFP❑ <br /> FACILITY ID# 144 <br /> ? .. CRoss REF ID# ACCOUNT ID# 5,391 INV# <br /> COMPLETE HE FOLLOWING BUSINESS I FACILITY SITE NF RMATI N' <br /> Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES El No IJ <br /> IS this an E)asTING Business LOCATION but a NEW TYPE of regulated Business? <br /> YES El No 1-1 <br /> BUSINESS/FACILITY/SITE NAME nj .. �� •' <br /> t <br /> SITE ADDRESS � - SUITE# BUSINESS PHONE <br /> CITY � STATE ZIP <br /> t <br /> ���1 <br /> is'DTRIC ocBoARJno <br /> ii <br /> Mailing Address ifDIFFERENThom Facility Address Attention:or Care Of(optional) <br /> Mailing Address City STATE ZIP <br /> SIC CODEAPN#. <br /> CDMMENC <br /> THIRD PARTY BILLING INFO: Comp/eteif Billing Party is different from Property Owner or Facility Operator identified above. <br /> BUSINESS NAME 1 Attention: re Of (optional) r <br /> Mailing Address *06 b i0 <br /> PHONE `/� �///►►► .�+ <br /> CITY STATE ZIP 4?Y5rr3 -.&tI <br /> dr f*f)1 tT dnncccc for fees and charges OWNER FACILITY/BUSINESS THIRD PARTY BILLING <br /> Rn t iNC •,Nn C'oNIPT LANCE ACKNOwLFDQNIENT: 1,the undersigned Applicant,certify that 1 am the Owner,Operator,or Authorized Agent of this Business,and 1 acknowledge that all PER.wrFEES, <br /> PE_VALTIES,ENFORCEVEVT CHARGES and/or HOURLYCHARGES associated with this operation will be billed to me at the address identified above as the 4CC-OUNTADDRF.S.0 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 SAN JOAQUIN 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,1 hereby authorize the release of <br /> any and all results and environmental assessment information to SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTINIENT as soon as it is available and at the same time it is <br /> provided to me or my represe five. <br /> PLEASE PRI <br /> APPLICANT NAME r SIGNATURE <br /> DRIVER'S LICENSE# <br /> TITLE (PHOTOCOPY REQUIRED <br /> a ApprovedBAccounting Off.-Processing Completed <br /> Date <br />