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San Juin County Environmental Health Department <br /> GREEN FORM <br /> DATE MASTER FILE RECORD INFORMATION "MFR" <br /> SH roEND �• UNIT IV <br /> OWNER FILE <br /> COMPLE7F 7HEFOLLOWlNG PROPERTY OWNER INPORMA770N.• CHECNIF OWNER Cf/RRENDYDNF NKo7f END ❑ <br /> PROPERTv OM'NER NAME PHONE <br /> First MI Last <br /> BUSINESS NAME / SOCSEC/TAJ(ID# <br /> Omer Home Address DC7 JmE <br /> DRR'S LICENSE <br /> City / STAZA0 _ 7a <br /> Owner Mailing Address f►yt- CS < rJ <br /> Mailing Address City State Zip <br /> Iver nr nwN.acure <br /> CORPORATIQN❑ INOMWAL❑ PARINER51IP❑ FED AGENCY❑ OTHER❑ <br /> FACILITY FILE <br /> FAatm ID# �oo c'c 5 C0.dss REF ID# ACCOUW ID# n oO � C r:. INv# . <br /> C0MPLE7]F7NEF0LL0WZ1VG <br /> BUSINESS I FACILITY I SITE 770111. <br /> 6 C 1d J j� <br /> Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YEs ❑ No ❑ <br /> Ls this an EXISTING Business LOCATION but a NEw TYPE of regulated Business? YEs ❑ No ❑ <br /> BustNEss/FAm.DY/SDE NAME <br /> SME ADDRrIC SUITE# BLEVIE55 PHONE <br /> CA- <br /> cm ST TE _Io <br /> Mailing Address i(DIFFERENr(tnm FadlitrAddress Attention:or Care Of(optional) <br /> Mailing Address City STATE zm N <br /> THIRD PARTY BILLING INFO: Completeif Billing Party is ditPerentfrom Property Owner or Facility Operator identified above. <br /> BU5INE55NAME CO rG� &-0"o / <br /> e- Attention:orCareOr (optlpsa/) <br /> Mailing Address 37S — C I// G � l PHONE <br /> CM Pll' a &A"L� 14, 1 rvvSATE 64[ z" 9 ys as <br /> ACCOMMnAnnncaa for fees and charges OWNER FACILITYBLISINESS THIRD PARTY BILLING <br /> 1111 t 1NG AND COMPI LANru ACKNOWI RDOMENT; I,the undersigned Applicant,certify that I am the Owner,Operator,or Authorized Agent of this Business,and I acknowledge that all PERMITFEFs, <br /> PENdLTim,ENFORCEMENTCHcniau and/or 110U LYCHARGES associated with this operation will be billed to me at the address identified above as the A(MUNTArrRieP 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 JOAQWN COUNTY Ordinance Codes and/or <br /> Standards and STATE and/or FEDERAL Laws aad Regulations.As the undersigned owner,operator,or agent ofthe 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 ARTMENd is available and al the same time it is <br /> ,provided to me or my representative. {Y/l'�(��Vs�L <br /> PLEASE PRINT <br /> APPLICANT NAME SIGNATURE <br /> TITLE DRNER'S LICENSE# <br /> (PNOTOCOPV REQUIREDI <br /> AppNmmd By rale 2 11 Accounting amass Processing completed By lT Data B <br /> 29-02-002 Aprd 25,2003 vi 1 <br /> • <br />