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San 46quin,County.:Environmental,Healt partment
<br /> 10 -'--"'qr4u .. �"L`Ln' be
<br /> ;DATE MASTER FIL%ERECORD INFORMATION "MFR" GREEN FORM
<br /> 5� 4W
<br /> UNIT IV
<br /> OWNER FILE
<br /> COMPI.ErETHE FOLLOWTNGPROPERTY OWNER INFORMATION; OAFJZF OWNER C1mRzNmrow,,"WTnNEHD ❑
<br /> PROPERWOMER
<br /> PHONE
<br /> NAME
<br /> F"I so MAI
<br /> BusiNm NAME
<br /> CA soc sec/TAX ID At
<br /> Owner Home Address
<br /> LicEissig
<br /> city
<br /> Owner l,szflIin,,Add. S I ran ZIP
<br /> Mailing Address City"
<br /> 5 1 It< I
<br /> zip
<br /> rl
<br /> !AirAl
<br /> U
<br /> R6 I'
<br /> D ,
<br /> -1f'A000UNT ID I'v
<br /> �22�ETETHEFQLLQ taBLISINE-C;-'; IFACILMISITFUEQAMTW-[Y.
<br /> Is this a NEw Business Lo Trots not previously regulated by the EN V[FUONMENTAL HEALTH DEPARTMENT? YES ❑ N.-[:]
<br /> xci
<br /> Is this an EsrING Business Lorwnonl but a NEW Ten of regulated Business 7 YES ❑ N
<br /> BUSINESS/7!2=7j,�n(
<br /> SITE ADDRESS
<br /> 115o sum# laummEss PNoNx
<br /> cm STATE zip
<br /> Saint 77 !7
<br /> "P�Supgnvts D
<br /> 4
<br /> Mailing Address ifDJ'FFER&VTf1n7 FadljtyAedTers
<br /> —Attention orCamOf(0PU, 0
<br /> az,
<br /> Mailing Address City
<br /> ---Zip.
<br /> SIC�CooELu 4
<br /> a"
<br /> HIRD PARTY BILLING INFO*. :M:E=01
<br /> 3USINEss NAI`IE Completeif Billing Party isdi"refrEntfmm Property Owner or Facility Operator identified above.
<br /> Attention:orCare of eopuonav
<br /> I)VNailing Address PHONE
<br /> Zip
<br /> for fees and charges OWNER FACILrry/13USINESS 'THIRD PARTY BILLING
<br /> I INC.ANI,CnA r r,%Nry ACKNOW, ,Ur.,,,NT: r,the undenigned Applicant,certify that I a.the 0,11,OP11-1-1,01,1-fh-.�iustAgen,I or this Basin r cut,I and I acknowledge that all pEArlr FE,,,
<br /> VALT'a,FNFORCEiVEATCUAIGEN And/.,11OV9LrCnAAGa 233ocialed with this operation win be billed In"-1 the address Ide-Iffildabove.,the jrrnrv Annarce for this die. I ala.certify that all
<br /> ,nvadon provided on this Application is true and correct;and that 211 regulated activities will be PcI--md I.accordance wilk all applicable SAN JOAQUIN COUNTY Ordinance Codnand/or
<br /> ndard3 and STATE and/or FEDERAL Laws and Regulations. As the inol,migned owner,0PCr2l0r,or agent of the property located at the above, facility/she address,I hereby a,thorineffi,"It.,of
<br /> and all results and environmental-as,s,.cnt Information to SAN JOAQUIN COUNTY ENVIRONNIENTAI,HEALTH DEPARTMENT as.soon as it Is available and at the same It.,it is
<br /> ,vidcd to me or my rcpr"cntad,c.
<br /> PLEASE PRINT
<br /> 11)4pLlCANTNAME SIGNATURE
<br /> TTLE DRIVER'S LICENSE#
<br /> �kDab,
<br /> ng"Cowple'ted By,
<br />
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