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San Joaquin County Environmental Health Department GREEN FORM <br /> OATS 41al I �� MASTER FILE RECORD INFORMATION "MFR" <br /> UNIT IV <br /> 4 r_ <br /> SJ'nnFn ARFAC FAR FHA IICF r1N1 V <br /> OWNER FILE <br /> CHECKIf OWNER CuRReivrzrorvFrtfwrrrr EHD ❑ <br /> COMPLETE THEFOLLOWING PROPERTY OWNER INFORMATION: PHON <br /> PROPERTY OWNER NAME 1 _ �r(�AUT R /1�/ t� • • `� �_ '� <br /> V ��•444 Mf Last Fr'r'' <br /> First <br /> �-^� t I , � <br /> Soc SEC/TAX ID# <br /> BUSINESS NAME 'SA , <br /> f. V 10 "D_p r�.` C�ew- <br /> , M <br /> DRIVERS LICENSE <br /> Owner Home Address i � 0 Q (C�t Y lr:� ��r <br /> � <br /> Cil�C-� -�Q V'\ SKATE <br /> city <br /> Owner Mailing Address dF�Y�n� <br /> d State Zip <br /> Mailing Address City <br /> TVDF r1F nl NFRGHiD <br /> CORPORATION❑ INDMElDUAL <br /> PARTNERSHIP❑ FD AGENCY OTHER <br /> ❑ <br /> FACILITY FILE <br /> CROSSREF IP AccoUNTID ` -�' INV# <br /> L - NF MAlow <br /> Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ No <br /> Is this an EXISTING Business LOCATION but a NEwTYPE of regulated Business? YES ❑ No <br /> BUSINESS/FACMM/SITE NAME , <br /> SITE ADDRESS • 1, SUITE# BUSINESS PHONE <br /> N $TATE ZIP <br /> CITY <br /> Mailing Address WDIFFERENTfrom FadlityAddress Attention:or Care Of(optional) <br /> Mailing Address City SLATE ZIP <br /> s; <br /> x ` <br /> THIRD PARTY BILLING INFO: Complete if Billing Party is different from Property Owner or Facility Operator identified above. <br /> BUSINESS NAME S / Attention:or Care option <br /> lK <br /> CoN Dor EAtz-TH ��cAq tvOtA6-tE l ' <br /> Mailing Address I 8 /\f W G �(r,-'C— �� PHo �Q <br /> ' -) <br /> QTY STo c� , aA/ STATE _� ZIP- I? <br /> Accau TADDR,ECC for fees and charges OWNER FACILITY/BUSINESS THIRD PARTY BILLING <br /> BILLING AND COMPI IANCF ACKNOWLEDGMENT: I,the undersigned Applicant,certify that I am the Owner,Operator,or Authorized Agent of this Business,and I acknowledge that all PERAnT FEES, <br /> PENALTIES,ENFORCEAfENTCr[ARGFS and/or HOURLYCHARGES associated with this operation will be billed to me at the address identified above as the ArrOTIAT.ADDRc 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 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,I hereby authorize the release of <br /> any and all results and environmental assessment information to SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as s on as it is available and at the same time it is <br /> provided to me or my represents e <br /> PLEASE PRINT <br /> t SIGNATUR <br /> �— <br /> E <br /> APPLICANT NAME aL / <br /> TIRE ��^� 2`' ��—�L �S DRIVER'S <br /> REQUIIR D# /iL ( Al2 <br /> Approved By •� Date Accounting Office Processing Completed By Date <br /> ra <br /> 29-02-002 April 25,2003 <br />