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4e. ,'San Joaquin County„_Pu6jlc�j-lealth Services_ En,Yjr.q.—k�toLffiealth',_Dlvlsion-.- <br /> s <br /> GREEN FORM <br /> DATE �G L. III1,6—w FILE RECORD INFORMATION "111 ' <br /> '^4� Yt"Y <br /> .g N_ADED AREAS FOR EHOVr[ONLY jOWN91D '�I!�s lt3 - . �. I. CABE� I `N� �s yl x„; ' � UNIT IV <br /> OWNER FILE <br /> COMPLETETHEFOLLOW/NG PROPERTY OWNER /NFORMAT(ON: CHEcKry OWNER CURRENrLyONF1LEHuTHEHD <br /> PROPERTY /I PHONE <br /> / <br /> OWNER NAME lit '�' Vn) <br /> FIV MI les( <br /> BUSINESS NAME SOC SEC I TAX ID E . <br /> Owner Home Address DRIVER'S LICENSE a <br /> City STATE ZIP <br /> Owner Mailing Address <br /> Mailing Address City Stale Zip <br /> CORPORATION❑ INDIVIDUAL O PARTNERSHIP❑ FED AGENCY GTHER❑ <br /> FACILITY FILE <br /> �a FAaLirvlDB '� � ORoss` EF ID AACCOUNT ID M”" <br /> COMPLETETHEFOLLOW/NG BUSINESS/FACILITY/SITE INFORMATION., <br /> Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DIVISION? YES ❑ NO <br /> Is this an EXISTING Business LOCATION but a NEW TYPE Of regulated Business 7 YES ❑ NO ❑ <br /> BUSINESS/FACILITY/SITE NAME p ^ C- - <br /> SITE ADDRESS �� 7 O��/\ f ) 11 1 ✓m!^ SUITE(f BUSINESS PHONE <br /> CITY <br /> STATE ZIP <br /> 1/J^` 7 7 <br /> �.BOARD OF SUPERVISOR �L��..L L LooATION CODE!_ ,,. KEY1. ..... ,.,,..:,«. 'w�..»�..�1K" <br /> Mailing Address ifD/FFERRENrfrom Facility Address Attention: or Care Of(optional) <br /> Mailing Address City STATE ZIP <br /> `SIC CODE .APN# COMMENT: ' <br /> THIRD PARTY BILLING INFO: Complete if Billing Party is different from Property Owner or Facility Operator identiled above. <br /> BUSINESS NAME ^ Attention:or Care Of (opfional) <br /> Mailing Address PHONE/� <br /> CITY STATE/k zip r/� <br /> A�s for fees and Charges OWNER FACILITY/BUSINESS THIRD PARTY BILLING l <br /> BUJANC AND COMPLIANCE ACKNOW LEDGMENI': 1,the undersigned Applicant,certify that I Sal the Owner,Operator,or Authorized Agent of this Business,and I acknowledge that all <br /> PERMIT FEEL,PENALTIES,ENFoRC'EtawTCHARGES and/or Houai-y CftARriES associated with this operation will he billed tome at the address identified above As the AL'Gnl/NTADnRESS <br /> for this site. 1 also certify that all information provided on this application is true and correct;and that all regulated activities will be performed in accordance with all applicable SAN <br /> JOAQUIN COUNTY Ordinance Codes and/or Standards and SrATE and/or FEDERAI,taws and Regulations. As the undersigned owner,operator,or agent of the property located at the <br /> above facility/site address, 1 hereby authorize the release of any and all resells and environmental assessment Information to SAN JOAQUIN COUN'1'V ENVIRONMENTAL <br /> HEALTH DIVISION as soon as it is available and at the same time it is provided tome or my representative. <br /> /. �-G- PLEASE PRINT <br /> APPLICANT NAME 'I '�.. SIGNATURE <br /> TITLE DRIVER'S LICENSE A <br /> IPHGTOCnPV RFOl11REnl <br /> ;AiapFoGedBy - lfeta Office PriSoeasingCoin leted8 -"',.+^ ,.,.,,• „, Dates":'" =^ <br />