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San Jauin County Environmental HealV apartment <br /> DATE GREEN FORM <br /> MASTER FILE RECORD INFORMATION "MFR" <br /> Sllenm.a cFHn .n <br /> OWNER ID# CASE <br /> # UNIT IV <br /> OWNER FILE <br /> COMPLETE THEFOLLOWING PROPERTY OWNER INFORMATION; CHECKIF OWNER CURRENTLYONFILEwrTHEHD ❑ <br /> PROPERTY OWNER PHONE <br /> NAME <br /> Hrsf MI last <br /> BUSINESS NAME SOC SEC/TAx ID# <br /> Owner Home Address DRIVER'S LICENSE# <br /> City STATE ZIP <br /> Owner Mailing Address <br /> Mailing Address City State Zip <br /> TYPF of OwNFRR[.HTP <br /> t'nppnP eTinN I I TNnMnI ie� I I DepTNFgcHTP I I FFn Arcury� (�TLJFp <br /> FACILITYID# CRDs REF ID# AccouNT ID# Inv# <br /> 2OMPIETE MEFOLLOWUVIG BUSINESS I FACILITY I SrrE LNFORMATIoN.' <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 NEW TYPE of regulated Business? YES ❑ No ❑ <br /> BUSINESS/FACILITY/SITE NAME <br /> SITE ADDRESS SUITE# BUSINESS PHONE <br /> CITY <br /> STATE ZIP <br /> BOARD OF SUPERVISOR DISTRICT I I LOCATION CODE I I I(EY1 I I KEyZ <br /> 1 11 <br /> Mailing Address ifDIFFERENTfrom Facility Address Attention:or Care Of(optional) <br /> Mailing Address City STATE ZIP <br /> SIC CODE APN# COMMEPIT <br /> 'HIRD PARTY BILLING INFO: Comp/eteif Billing Party isdifferentfrom Property Owner or Facility Operator identified above. <br /> BUSINESS NAME Attention:or Care Of (optional) <br /> Mailing Address PHONE <br /> CITY STATE ZIP <br /> dc�a^^RFCs for fees and charges OWNER FACILITY/BUSINESS THIRD PARTY BILLING <br /> it t INC AND C(NiPt IANCF ACKNONNI FDCveaT: 1,the undersigned Applicant,certify that 1 am the Owner,Operator,or Authori.ed Agent of this Business,and 1 aclmo"ledge that all PER.It/T FF-ES, <br /> TAALT/ES,EAPORCE.tfE.TCHARGES and/or 1101 RLYCILARGES associated with this operation"ill he billed to me at the address Identified above as the Accot'yT ADORFSC for this site. 1 also certify that all <br /> formation provided on this application is true and correct;and that all regulated activities will be performed in accordance with all applicable SAN JO.AQUIN COUNTY Ordinance Codes and/or <br /> andards and STATE and/or FEDERAL Laws and Regulations. As the undersigned o"ner,operator,or agent of the property located at the above facility/site address,1 herebv authorize the release of <br /> nand all results and environmental assessment information to SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br /> -ovided to me or my representative. <br /> PLEASE PRINT <br /> APPLICANT NAME SIGNATURE <br /> TITLE DRIVER'S LICENSE# <br /> (PHOTOCOPY REQUIRED) <br /> Approved By Date Accounting Office Processing Completed By pate <br />