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s-/ E(-3 Z_ <br /> San Joa4uin County Environmental Health Department <br /> GREEN FORM <br /> DATE MASTER FILE RECORD INFORMATION "MFR" <br /> SHAnFn eRFec FnC FHA usE nNi r OWNER ID# T— CASE# UNIT IV <br /> OWNER FILE <br /> COMPLETE rHEFOLLOwINGPROPERTY OWNER INFORMATION; t ymcrF OWNER CURRENnYON FILE WrTN EHD <br /> PROPERTY OWNER NAME PHONE <br /> ( First Mt Last <br /> BUSINESS NAME I $oc SEC/TAx ID# <br /> Owner Home Address DRIVER'S LICENSE# <br /> City STATE ZIP <br /> 2-t vet )c <br /> Owner Mailing Address r1 <br /> �ti .n tt�YC �a <br /> Mailing Address City \ State 7 Zip <br /> ..Im�n •t � <br /> TVoF nF QwNFQCH7P <br /> CORPORATION ID INDMDUAL❑ PARTNERSHIPP FED AGENCY❑ OTHER❑ <br /> FACILITY FILE <br /> FACILITY ID# CROSS REF ID# AccouNT ID# INV# <br /> COMPLETE rHEFOLLOWING BUSINESS I FACILITY I SITE INFORMA77-ON.- <br /> Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ No,9 <br /> Is this an EXISTING Business LOCATION but a NEW TYPE of regulated Business? YES ❑ No <br /> BUSINESS/FACILITY/SITE NAMEC eZ <br /> v JP4 ��rt t ttml �•� L.P c rxtr.� <br /> SITE ADDRESS ! t SUITE# BUSINESS PHONE <br /> CITY STATE CA ZIP `15W3 <br /> BOARDOF SUPERVISOR DISTRICT LOCATION CODE KEYS KEY2 <br /> Mailing Address ifDIFFERENTfrom FadlityAddress Attention:or Care Of(optional) <br /> Mailing Address City STATE ZIP <br /> 1KC— <br /> APN# COMMENT: <br /> THIRD PARTY BILLING INFO: Complete if Billing Party is different from Property Owner or Facility Operator identified above. <br /> BUSINESS NAME Attention:orCare Of ( a/) <br /> Al� /��- S,c4l'A' <br /> Mailing Address SIN ��c to 4StV S IOb PHONE <br /> CITY 17r tk t�•[r✓�+/1 SAAa ZSP <br /> ccaluvr dnncccc for fees and charges OWNER FACILITY/BUSINESS �T� THIRD PARTY BILLING <br /> Rn i rvc twt('Ovtei t.tv[E Ac�:�mtt.E ncstevr: L the undersigned Applicant,certify that 1 am the Owner,Operator,or.luthoriced.agent of this Business,and 1 acknowledge that all PERA11T Fees', <br /> PE:v:ttneS,E.%FORCEMEATCH.tRGts and/or Hot RL v CHARGES associated with this operation will be billed to me at the address identified above as the.accot%T.Long F-cy for this site. I also certify that <br /> all information provided on this application is true and correct.and that all regulated activities will he performed in accordance with all applicable SA.,JOAQUI',COU'ITV Ordinance Codes and/or <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,l hereby authorize the release of <br /> any and all results and environmental assessment information to SAV JOAQU'IN COUNTY EVFIRONNIENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my representative. <br /> PL PRINT <br /> APPLICANT NAME 1 iA/t r`Ct�l t SIGNATURE �� u <br /> TITLE 1 DRIVER'S LICENSE# <br /> tL r <br /> AtOnt �{"o>� t-D a1.a t (PHOTOCOPY <br /> Approved By Date Accounting Office Processing Completed By Date <br /> 39-02-002 Aprit'_i.'--001 <br />