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-:7f <br /> �[� `moi , •„_- ----,sew-- tG ICr a f yA:�-f L_y It y� _ is <br /> • DATE MASTER FILE RECORD INFORMATION "&,FR" GREEN FORM <br /> UW <br /> UNIT IV <br /> OWNER FILE ^ <br /> COMPLETE THE FOLLOWING PROPERTY OWNER INFORMATION: C�ecK(a OWNER CURwENTtY0NFILEwiTHEHD <br /> PROPERTY TAe /157l (/h'q"-"14h1e PHONE <br /> �? G <br /> OWNER NAME I�L r►f�/n�lra 7-44,:� — ���� (S 442 <br /> firr MI rAs( <br /> BUSINESS NAME I SOC SEC/TAX 10 M <br /> Owner Home Address yDz 5 , /�21i / vC� DRIVER'S LICENSE S G <br /> City STATE C-''t ZIP (6-20 <br /> Owner Va Iing Addresa A <br /> Mailing Address City State Zip <br /> CORPORATION Cl INDIVIDUAL❑ PARTNERSHIP❑ FEO AGENCY❑ OTNER❑ <br /> FACILITY FILE <br /> - <br /> Eactrti57D <br /> 7--5ACC <br /> r_ - ACCOU <br /> COMPLETETHEFOLLOW/NG BUSINESS / FACILITY/ SITE INFORMATION: <br /> Is this a NEW Business LOCATION not previoUily regulated by the ENVIRONMENTAL HEALTH OIV131ON 7 YES ❑ NO g <br /> Is this an EXISTING Business LOCATION but a NEW TYPE Of regulated Business YES ❑ No <br /> BUSINES3/FACILITY/SITE NAME (/ <br /> auzG/L <br /> SITE AOOREss SUITE R BUSINESS PHONE <br /> CITY / STATE ZIP <br /> �..:BMAFW0E-SMPE9YW0R <br /> l 1�C ��✓` tS �,,,�,.t�� _ 1F _. -- rF �� _ '. I <br /> Mailing Address it'DIFFERENT freirrr FacilifyAddr'ess Attention: of,Caro Of(optional) <br /> 25-0 E. fT' M kjo t <br /> T <br /> Mailing Address City 6e // STATE � Z:P <br /> ` C' 9Soo8 <br /> ILI <br /> THIRD PARTY BILLi- a INFO; Complete if Billing Party is different from Property Owner or-Facility Op.--ator identifiedab(., �. <br /> BUSINESS NAMe e / Attention: orCare Of (optional) <br /> V R/� La/rGrl s Ul(tl Gti L.� PT Ali i 'o't <br /> Mailing Address Z,SO ,/ vt C /� PHONE �Qo8 l a-3( - 0 8 3g <br /> CITY // v STATE ZIP C� !QO p <br /> dCCOUA?AOORESS for fees and charges OWNER FACILITY/BUSINESS THIRD PARTY BILLING <br /> RILLINC AND COMILIANCE.ACKNOwI.EDGMENT: 1,the undersigned Applicant,certify that I Am the Owner,Operator,or AuNrorized.,Igen!of this Business,and I acknowledge that all PLRM17FEF)'. <br /> PEivAL17Ef,E,vFpRCZtfFvrCHARGES and/or HOLRtrottRGGs aasoc[ated with this operation will be billed to one At the address identified above As the ACCIAWrADDRFS4 for this site. I also certify that <br /> all information provided on this appik3doet is true and correct;and that all regulated activities will be performed in accordance with Al appiicable SAN JOAQUIN COUNTY Ordinance Codes and/or <br /> Standards and STATE and/or FEDERAL Laws and Regulations. As the undersigned owner,operator,or stent of the property located At the abuve facility/site address,I hereby Authorize the release of <br /> Any And all results Sul environmental assessment information to SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DIVISION as soon as it is available and at the same time it is provided to <br /> me or my representative. <br /> �> P 9E PRINT <br /> APPLICANT NAME >• �L�G �� SIGNATURE <br /> C G DRIVER'S LICENSE K <br /> TITLE Gt COIBri ! fe442B t 3� <br /> S (PHOTOCOPY REQUIRED) <br /> aRq�alle�t3Y', �T, , .:`, Ss�,,a+ ?ttasialu�+�laa_ e�sbneSosnotetat8 � Date <br /> v lcZS T <br />