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San•iquin County,Environmental He Department <br /> GREEN FORM <br /> DATE MASTER FILE RECORD INFORMATION TTMFRTF <br /> OWNERID# ce # UNIT IV <br /> OWNER FILE <br /> COMPLErE THE FOLLOWING PROPERTY OWNER INFORMATION; CH£CNIF OWNER CURRENnroNFILEwrrrrtHD <br /> PROPERTY OWNER PHONE <br /> NAME <br /> First MI last <br /> BUSINESSNAME Sac SEC/TaxID# <br /> L <br /> Owner Home Address DRIVER'S LICENSE# <br /> City STATE zip <br /> Owner Mailing Mtl� >> <br /> Mailing Address City �/� �;. L /1 -14U/e Statelf_/�-. Zip �s-33 0 <br /> roc nc nwrv�Rw,P <br /> rna ..n TwnnnnHM n oaa a n �.,.Accwry n <br /> FACILITY ID# ; . . CROsS REF ID# > MCOUNT ID# Inv# <br /> Is this a NEw Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ No ❑ <br /> Is this an EMSTING Business LocAnoeibut a NEW TYPE of regulated Business? YES ❑ No ❑ <br /> BUSINESS/FAauTr/ ITE AME <br /> SITE ADDRESS SUITE# BUSINESS PHONE <br /> STATE <br /> Cm uP C7 <br /> BoARo of SUPERVISOR DISTR[cr I I Locwnon Come .I ,I Ken:. I I KEr2. <br /> ._ .. — <br /> Mailing Address WDIFFERENTFToYn FacilityAddress Attention:or Care Of( lona/) <br /> Mailing Address City STATE LP <br /> SIC CooE -;.. •�� AVN#'::,.. , r .;;�'., COMMENT: .. .. ::.... .. 'r ., .is...:=' : ,•-_ _ .�.�5= <br /> THIRD PARTY BILLING INFO; Complete/f Billing Party is differentfrom Property Owner or Facility Operator identifiedabove. <br /> BUSINEss NAME Attention:or Care Of (optional) <br /> Mailing Address PHONE <br /> Cm STATE ZIP <br /> d!r'nl ffiTA WEBS for fees and charges OWNER FACILITY/BUSINESS THIRD PARTY BILLING <br /> 1,the undersigned Applicant,certify that I..the Owneq Operator,or Anhori.ed Agent of this Business,and I acknowledge that all PERMIT FEES, <br /> PEb'ALTics,ENFORCEmEATO ARGFS and/or I/OURLYCHARGES associated with this operation will be billed tome at the address identified above as the IrronvT.tnnercc for this site. I also cerfify that 28 <br /> Information provided on this application is true and correct; and that all regulated activities will be performed in accordance with all applicable SAN JOAQUm COUNTY Ordinance Codes andlor <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 soon as it is available and at the same fime It u <br /> provided to me or my representafive. <br /> PRASE Pmw <br /> APPLICANT NAME SIGNATURE <br /> TITLE DRIVER'S LICENSE# <br /> (PHOTOCOPY REOUIREDI <br /> Approved By ...* <br /> y IDate .. Acoountin90ffice Processing BY. .. Date ssg _ <br />