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San Joaquin County Public Health Services Environmental Health Division <br /> � GREEN FORM <br /> DATE — Z�-��l MAS r �R FILE RECORD INFORMATION ` t t,R" <br /> UNIT IV <br /> //ADEQ AREA9.FOfj EMD USL ONLY OWNER ID# I •� J` -�" I CASE# I <br /> OWNER FILE <br /> COMPLETETHEFOLLOW/NG PROPERTY OWNER INFORMATION.' CHEcx1F OWNER CURRENTLYON FILE W/rivEHD <br /> PROPERTY � l�� / PHONE <br /> �J/ <br /> OWNER NAME �/ �/' /L'_ '� <br /> F-1 MI Ina] <br /> BUSINESS NAME t/ Srac�/r-r�� SOC SEC/TAX ID# <br /> Owner Home Address /7, DRIVER'S LICENSE# <br /> city STATE 606— ZIP <br /> Owner Mailing Address <br /> Mailing Address City State� ' Zip c7 �I—G, <br /> CORPORATIONS INDIVIDUAL❑ PARTNERSHIP❑ FED AGENCY❑ OTHER❑ <br /> FACILITY FILE <br /> FACILITY ID# CROSS REF ID# ACCOUNT ID# INV# <br /> COMPLETE TTIEFOLLOW/NG BUSINESS I FACILITY/ SITE /NFORMAT/ON: <br /> Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DIVISION 7 YES ❑ NO (� <br /> Is this an EXISTING Business LOCATION but a NEW TYPE Of regulated Business 7 YES ❑ NO <br /> BUSINESS/FACILITY/SITE NAME 1 <br /> 101e/Loz A/.ITJZ/,Cd <br /> SITE ADDRESS SUITE# BUSINESS PHONE <br /> CITY � ,� �., / � STATE ZIP L1 C�D2 <br /> I.BOARD OF SUPERVISOR I I LOCATIONCODE. I I KEYS I KEY2 <br /> Mailing Address if DIFFERENT from Facility Address Attention: or Care Of(optional) <br /> Mailing Address City STATE ZIP <br /> SIC CODE APN# COMMENT: <br /> THIRD PARTY BILLING INFO: Con7/viete if Billing Party is different from Property Owner or Facility Operator identified above. <br /> BUSINESS NAME /' /7S Attention: or are O optional) <br /> Mailing Address /�© 2a� 7/ ?,O PHONE��,�y <br /> CITY G /��L ���.U/ — -a 6_3 iD STATE ZIP <br /> Al2GOVIYTAODREss for fees and charges OWNER FACILITY/BUSINESS THIRD PARTY BILLING <br /> BILLING AND COPIf I.IANc'E A('6N)W l.t:l)(;NIENT: I,the undersigned Applicant,certify that I and the(honer,Operator,or Authorized Agent of this Business,and I acknowledge that all <br /> PERMIT FEF_c,PfN4L77EY,ENFPRL'L:.iIFNTCIIARGES and/or NUURI.Y(•II.4RGE'J{SyCiatcd will)Ihis opeY ion will he billet]tonic at the address identified above as the ACCOUNT,41WRE%s <br /> for this site. I also certify that all information provided on this applic ti Nile and correct;and, tall regulated activities will be performed in accordance with all applicable SAN <br /> JOAQu1N COUNTY Ordinance Cocks and/or Standards and STATE and eUFRSI.Landlitwb ytdlltl���--ns. As the undersign ner,operator,or c of the property located at the <br /> above Gtcility/site address, 1 hereby authorize the release of any and all resulls and environmental assessment infun atiul d, SAN JOA IIN 'OUN'TY ENVIRONMENTAL. <br /> HEALTH DIVISION as soon as it is a%ailahic and al the same tine it is provided to nic or any representative. <br /> NFID N <br /> PLEASE PRINT <br /> APPLICANT NAME G' ( �/t!7�{ )� SIGNATURE <br /> ��� — s�� � �� RIVER'S LICENSE# <br /> TITLE <br /> PHOTO .OPY RFOLIIRF-Dl <br /> Approved By L Date / Accounting Office Processing Completed By Date <br />