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San Joaquin County Environmental Health Department <br /> DATE11 �/ 6 MASTER FILE RECORD INFORMATION "MFR" GREEN FORM <br /> q"AnFn ARFAQ Fm FNA uac nmiy �(� D 7 <br /> UNIT IV <br /> OWNER FILE <br /> CbMPLETFTHEFOLLOWINGPROPERTY OWNER INFORMATION.' <br /> CHECK IF OWNER CURRENTLYONFRE WITH E H D <br /> PROPERTY OWNER NAME /'� /y �-�'y f PHONE <br /> J First MI / ( Last — ✓' `]�, �cJ K_/ <br /> BUSINESS NAMEf SOC SEC/TAX ID#��/��- <br /> Owner Home Address <br /> / - DRIVER'S LICENSE# IP C/yy,V <br /> city — STATEJ ( & Z <br /> Owner Mailing Address <br /> ' <br /> t' <br /> Mailing Address City State Zip <br /> G � <br /> TURF r1F n1 FRRNap <br /> CORPORATION❑ INDMDUALK PARTNERSHIP❑ FED AGENCY❑ OTHER❑ <br /> FACILITY FILE <br /> FACILITY ID# CROSS REF ID# Ac[ouNT ID# 1MA,7,3&7 <br /> Inv# <br /> MP ETF 7HEFOLLOWrIV6 BUSINESS I FACILITY I SITE INFORMA770N., rr�� <br /> Is this a NEW Business LOCATION not Previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES El No YU <br /> Is this an EXISTING Business LOCATION but a NEW TYPE of regulated Business? YES No ❑ <br /> BUSINESS/FACIISTY/SITE NAME <br /> SITE ADDRESS3 5� CL�L�-S,y ' L'�t-t SUITE# BUSINESS PHONE <br /> CITY C //T/ l• $TATE ZIP <br /> Mailing Address WDIFFERENTfirmtn Fad/ityAddness Attention:or Care Of(optional) <br /> Mailing Address City j `�7r�L^���^ STATE� yl ZIP <br /> y <br /> THIRD PARTY BILLING INFO; Complete,f Billing Party is different from Property Owner or Facility Operator identified above. <br /> BUSINESS NAME Attention:or Care Of (opdona/) <br /> Mailing Address PHONE 1 <br /> Cm STATE ZIP <br /> erQUNj e,PR"s for fees and charges OWNER <br /> FACILITY/BUSINESS THIRD PARTY BILLING <br /> 1111.1,ING AND(-OMPt.0 NCe.eCxrvowl.encMFNT; 1,the undersigned Applicant,certify that I am the Owner,Operator,or Authorized Agent of this Business,and I acknowledge that all PERMIT FEES, <br /> PEN'ALTTES,ENFORCEbtF.NTCHARGES and/or HOURLYCHARGFS associated with this operation will be billed tome at the address identified above as the ACCOUATADDRFC.0 for this site. 1 also certify that <br /> all information provided on this application is true and correct;and that all regulated activities will be performed in accordance with all applicable SAN JOAQUTN COUNTY 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,I hereby authorize the release of <br /> any and all results and environmental assessment information to SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPART �T as soon as it is available an a;7e time it is <br /> provided to me or my representative. <br /> APPLICANT NAME �� i � SIGNATURE <br /> TITLE //I ( 1 l�7� DRIVER'S LICENSE# K� <br /> (PHOTOCOPY REQUIRED) <br /> Approved By Dabs Accounting Office Processing Completed By Date <br /> 29-0-02-002 April 25,'_003 <br />