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a a: r S yi �7t'y�,(py ^M' LP,' S''-#+33fq',�y 4�' p Y <br /> 1�01�� <br /> GREEN FORM <br /> DATE J, `�I C`7 MASTER FILE RECORD INFORMATION ` MFR" <br /> OWNER ID# l✓�-" V 1 CASE# UNIT IV <br /> OWNER FILE <br /> COMPLETE THE FOLLOWING PROPERTY OWNER INFORMATION: CHECKIF OWNER CuRREnrcroHFtLEwrrHEHD <br /> PROPERTY OWNER (1l f1 }(`- ', / PHONE <br /> NAME ✓. - �v�l<< O � U; <br /> First MI last <br /> BUSINESS NAMET-!7 � I-/ h SOC SEC/TAX ID# e <br /> �� D QGl CL eO fGGt G <br /> Owner Home Address DRIVER'S LICENSE# <br /> city STATE ZIP <br /> tJ� <br /> Owner Mailing Address <br /> Mailing Address CityC State Zip <br /> TVPF or nWNFRGH7P J <br /> r"AP PAP eTiAN TNnMAllel I_1 DeRrNFP cu1P I J F—ArF.—L) nTL1FR I _I <br /> IrIl F: <br /> FACILITY ID# d ✓„ti i CROSS REQ ID# AccouNT ID# 90 7 L A INv# i <br /> COMPLETE HEF LL WING BUSINESS I FACILM I SITE INFORMATION: <br /> Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ No ❑ <br /> Is this an EXISTING Business LOCATION but a NEW TYPE of regulated Business? YES ❑ No ❑ <br /> BUSINESS FACIIITY/SITE NAME <br /> SITE ADDRESS SUITE# BUSINESS PHONE <br /> © �3-2Gao <br /> Cm �� � STaTt: ZIP <br /> IIBOARD OF$UPERYISOR D „rsL I LOCATION CODE I I KEYl <br /> Mailing Address ifDIFFERENTfrom Fad/ityAddress / Attention:or Care Of optional) <br /> Mailing Address City STATE ZIP <br /> $IC CODE APN# COMMENT: <br /> THIRD PARTY BILLING INFO: Complete if Billing Party is differentfrom Property Owner or Facility Operator identified above. <br /> BUSINESS NAME � �C / C Attention:or Care Of (optional) <br /> Mailing AddressPHONE <br /> /o z �i6. 3- <br /> CITY /�/ STATE 5;11– ZIP p� <br /> ACCaLWI d DRESS for fees and charges OWNER FACILITY/BUSINESS THIRD PARTY RILLINNNG <br /> Rn t INr ANn C", tsvrr•'.Ar w'LFDCN1FNT: 1,the undersigned Applicant,certify that I am the Owner,Operator,or Authorized Agent of this Business,and I acknowledge that all PERJUT FEES, <br /> PENALTIES,ENFORCEatENTCHARGEs and/or llouRLrCHaRGES associated with this operation will be billed to me at the address identified above as the Arrot'VrAnnRFs. for this site. I also certify that all <br /> information provided on this application is true and correct; and all regulated activities will be performed in accordance with all applicable SAry JOAQUIN COUN-n Ordinance Codes and/or <br /> Standards and STATE and/or FEDERAL Laws and Regulations . As th undersigned owner,operator,or agent of the property located at the above facility/site address,1 hereby authorize the release of <br /> any and all results and environmental assess nl inform on to S N JOA COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my representative. <br /> PL P NT <br /> APPLICANT NAME ���f> <br /> �6 99&& 7VcS TURE <br /> TITLE DRIVER'S <br /> LICENSE# <br /> Gr��l1'y J� (fil,fO70CLiPYFE0Y7AED) ! �t 44 <br /> Approved By Date AOooun ` g Office Processing Completed B Date (J J <br />