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San Joaquin County Environmental Health Department <br /> GREEN FORM <br /> IMTE (�G1 MASTER FILE RECORD INFORMATION "MFR" <br /> r y UNIT IV <br /> 0l'3000 U OWNER FIL! <br /> ' L7ftal if OWNER etArReHrrravrraettmH END <br /> OWNER <br /> P"DMWlY Owltet HAM PHOrE <br /> First M/ last <br /> stt�egs NAFt r <br /> SOC Sec/TAX M# <br /> Owrrr 1IIis Address DRIVEit'S LKENN tY <br /> ClIty STATE ZIP <br /> OtaNaar Malaew Address 8Q2� 912- <br /> Mtairtp AtldtwY Staff <br /> Cww"Twm❑ DOrVMULL❑ PAIROMRISHM❑ FED AGENCY❑ OTMpt❑ <br /> a 0 $ 0 FAcamr Fax �a 1 <br /> !. 4 4 4do <br /> ft <br /> S , <br /> "" , <br /> is d*a New ersimm LocmoN not previously repldatad by the Erw[ROHNEwAL HEALTH DEPARTMENT? YEe ❑ Ho <br /> is UTIs an Euvrow Businaas L o non but a New"o(reptilaW dust m"? YES ❑ NO L� <br /> iuoss/FACZJTv/SrrE HAMkbL V1 N V <br /> Sm ADOIIE56 StuTE* 6iDIIlSS PHONE <br /> 12 <br /> QTY STATE ZIP - <br /> Malirtp Addtw.V DVE94fffftm AoditAddass L41 t; Atbantlon:or arc Of(opdomg <br /> Malilw Add—aY STATE <br /> 'lCr�P� <br /> TNMe'AWY 51ILLM INFO: C&Wkte K 811 ing Party /s diffemntffvm Property owner orFacUfty Operator Oentifiedabove. <br /> sues NA►! I J l/ I AttentWn:ore or (apblonag <br /> Mailkrp Address G Q Id, /Y• W <br /> QTY STATE ZIP <br /> AmwazAaam sF ler lees and dtaW OWNER FACMJTY/BUSINE!SS THIRD PARTY BILLING <br /> 1k111jNC.AMjrflMI4j.sers Atl NOWT nraeaNr 1,the undersigned Applicant,certify that Ism the Owner,Operator,er AutAoHzed Agelrt of thb Business,and 1 acknowledge that all PEPMT FEES, <br /> PENALTTEt,E1VF0RCZ1 FMCHAAC,S and/or HOURLY CHANGM associated with this operation will be billed to me at the address identified above as the ACCO NTAIMAPST for this site. 1 abo certify that <br /> "I <br /> W <br /> information proved on this application is true and correct;and that all regulated activities will be performed in accordance with all applicable SAN JOAQUIN COUNOrdinance Codes OrdinaCodes and/or <br /> Standards and STATE and/or FEDERAL Laws sad Regulations. As the undersigned owner,operator,or agent of the property located st the above facihty/aite address,1 hereby authorize the release of <br /> any sad as results and environmental assessment information to SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARENT as soon u N 4 available cad at the name time it is <br /> .provided to me or myrcpr tative. r•'VIII J ' <br /> APPLICANT NAME I �1I� I PLEASE PRINT SIGNATURE <br /> TITLE A DRIVER'S LICENSE x <br /> Y (MM000PY MQUIRED) <br /> gpettad M Dela A--Abw Onloa It oeamb Corttpia6ad Or Dts6e O �� O <br /> 29-02-002 April 27,21x17 <br />