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16 <br /> San Joaquin County Environmental Health Department <br /> DA-ii I GREEN FORM <br /> MASTER FILE RECORD INFORMA�TIO7,j !71 <br /> CASE# <br /> :01:t:.E: <br /> 514AIMED AREAS POR FHn HrF am # <br /> Nip/'�PL-5-9 " UNIT IV <br /> OWNER FILE <br /> COMPLETE-THEFOLLO WING PROP E OWNER INFoRmATioN., EHD <br /> PROPERTY OWNER NAME <br /> First <br /> irst Last <br /> BUSINESS NAME Soc Sec I TAx ID# <br /> Owner HonAddress <br /> DRrvER's LICENsE 4 <br /> t <br /> city —5 7� STATEC"�4 Z-I­P�� <br /> t 4;' <br /> Owner Mailing Address <br /> MaiYng Address City State Zip <br /> TywnFr1wm1LavA4TP <br /> coRpopAmri El INDWIDUALM PAMWE16MIP FED Ar-eNcy <br /> FACILITY FILE <br /> FA( Lrrf M# CRoss REF ID# ACCOUNT ID# Z/ NV# <br /> 1l9Pj5j21fZ 1 1 1 1 <br /> rHEFOI.Ialmm BUSINESS I FACILrEY I SITE&EVAMIZZON. <br /> Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES 13 NO Or, <br /> Is this an E)asTING Business LOCATION but a NEW TYPE of regulated Business? YES El No ER, <br /> SUSMESSjFAaLnY/SrrE NAME <br /> SIn"DRESS / '3 -L( '�, <br /> SurrE# 13USINESS PHONE <br /> CITY �� ZIP <br /> 13OARDOFSUPERVISOR DISTRICT LOCA-0N CODE KEY2 I <br /> Mailing Address ffD1FPEREArr,6'vm Fac7"1j&'yAddrjmw Attention:or Care Of(aptkwl) <br /> / 4s % 1 <br /> Mailing Address City9 < <br /> sr&- 'l— <br /> zip <br /> [SIC�CIDe APN# COMMENT: <br /> TKIRD PARTY BILLING INFO.- Complete if Billing Party is different from Property Owner or Facility Operator ident#Wabove. <br /> BUSINESS NAME Attention:orCare Of (qptfoaal) <br /> Mailing Address PHONE <br /> CITY STATE ZIP <br /> ACrawim-AnaRms for fees and charges OWNER FACILITY/Busmss THIRD PARTY BILLING <br /> 1111 1 INC AND CONIPS signed Applicant,certify that I am the Owner,Operator,or Authorized Agent of this Business,and I acknowledge that all PERWT FEES, <br /> -1 C11ARGES an h et: 1,the undersigned <br /> PENALTIES,ENFORC-3fEAT ROURLYCHARCES associated with this operation will be billed to me at the address identified above as the ticCOUNTADOResc for this site. I also cortifv that all <br /> information provided on this application is true and correct, and that all regulated activities will he performed in accordance with all applicable SAN JOAQUINCOUN't-v Ordinance Codes and?or <br /> Standards and STATE andfor FEDERAL Laws and Regulations. As the undersigned owner,operator,or agent of the property located at the above r2cility/site address,I hereby authorize the release of <br /> an) and all results and environmental assessment information to SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my representath fr <br /> APPLICANT NAME Pl."PRINT <br /> Z- SIGNATURE <br /> TITLE99 DRIVER'S LICENSE# <br /> (PHOTOCOfrY REOU4RED) <br /> Approved ` Date Accounting Office Processing Completed BY ©a'6e. �1 JJJ <br /> 29-02-02 April 2�,2003 <br />