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1142 GREEN FORM <br /> MASTER FILE RECORD INFORMATION ��MFR" X12 OD`t.1-r7 S- <br /> I - o <br /> UNIT IV <br /> OWNER FILE <br /> COMPLETE 7l/EFOLL014TNG PROPERTY OWNER INFORMATION; O+ win OWNER CwREIYTLYovFnxwrrHEHD <br /> PROPER"OWNER } � S 1-4-� C t, � P, PNONE o <br /> NAME - <br /> Fkst 11 M! last <br /> Bttslrtrss NAME {� Soc SEC/TAX ID# <br /> Owner Hone Address , / Drover's L amm# <br /> City STATE ZIP <br /> Osmw Maip Adbtrs 7 9 -Fzlp <br /> MaNV AW—C suft7X <br /> rYrri..,..y,❑ tn.,svrntsar❑ otte,....rro FA,1r�ewv❑ nr,«�❑ <br /> IF <br /> LS this a New buskllliis LOCATION not previously regulated by the ENvmONMBITAL HEALTH DEPARTMENT? YES ❑ No ❑ <br /> Is this an NXMTM irisiftass LOCATION but a NEw TYPE of regulated Business 7 Yes ❑ No ❑ <br /> sussNes/FACMM/Sne NAME / <br /> -Ze/ <br /> SITE ADDRESS a SrmE# B MNEss PHONE <br /> s — K <br /> CITY STA7� J 20 <br /> Mailhq Addnm 1f0DMWffftm FidNtyAddress Attention:or Care Of(opdonal) <br /> McAng Addmw City STATE ZIP <br /> Masai <br /> r►+L pAnfrY ELuaNa INFO: Complete if Billing Party is different Mom Property Owner or Fadlity Openftr A*yWfied above. <br /> Busatess NAME - Attention:arCona Or (optiFarM) <br /> ZC/ 7 k)&Sfe <br /> MNlirrp Address PrafE _ _ <br /> CITY 9 <br /> $TATE ZZP <br /> for few and charges OWNER FACILITY/BUSINESSTHIRD PARTY RK-I..IN <br /> YI i mr.ANn cnmr!. NCr Ar'YNnwl Fnrmr.NT: 1,the undersigned Applicant,certify that I am the Owner,Operator,or Authorized Agent of this Bualans,and I acknowledge that all PER.WIT FEES <br /> 'ENALTms,ENF»RCtMENTCXARces and/or HouRLYCHARcFs associated with dJs operation will be billed to me at the address kkndfied above as the ArrnrmTAnnRPcr for this site. I also certify that all <br /> sformatbn provided on this application is true and correct;and that all regulated activities will be performed in accordance with all applicable SAN JOAQUIN COUNTY Ordinance Codes and/or <br /> aasdards 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 /> Ery sad as results sad environmental assessment information to SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It is available and at the same time It Is <br /> rovided to me or my representative. <br /> PLEASE <br /> APPLICANT NAME SIGNATURE <br /> D y <br /> "000' —;�Or <br /> TITLE ` l (PHOTOLICEN ME <br /> t�Y� R OOUVM) <br /> J <br />