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GREEN FORM <br /> DATE 3 ' MA FILE RECORD INFORMATION <br /> SHADED AREAS roR EH USE ONLY . N 4 b, � UNIT IV <br /> . T+ <br /> tJ LJVQ (4 4 �-( OWNER FILE <br /> COMPLETE THE FOLLOWING PROPERTY OWNER INFORMATION; CHECKIF OWNER CuaREHrcroNFzLEwrrHEHD ❑ <br /> PROPERTY OWNER / 'S C PHONE <br /> NAME c'-,"'dc") 6L'Ic'y <br /> First MI last <br /> BUSINESS NAME SOC SEC/TAX ID# <br /> CA,�;alacl s. (��,.fay FA.r;ly irtisT <br /> Owner Home Address DRIvER's LICENSE# <br /> (�5'3 G�lco,So .Ave.Itie, <br /> city STOC'kTo,A STATE CA zip �5-20o <br /> Owner Mailing Address <br /> so'r C- <br /> Mailing Address City State Zip <br /> TYPE OF OWNERSHIP <br /> CORPORATION❑ INDIVIDUAL❑ PARTNERSHIP❑ FED AGENCY❑ OTHER❑ <br /> FACILITY FILE )'p(g <br /> ,3!v e a F ii.kA�� <br /> S.fr.C�`sq''y, ri'^:S' .k,7!. .:.S�tr, �9�'r , � <br /> COMPLETETHE FOLLOWING BUSINESS FACILITY SITE INFORMATION; <br /> IS this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DIVISION? YES No ❑ <br /> Is this an EXISTING Business LOCATION but a NEw TYPE of regulated Business? YES ❑ No ❑ <br /> BUSINESS/ <br /> rFACILITY/SITE N�A�ME <br /> I.124U °P <br /> SITE ADDRESS SUITE# BUSINESS PHONE <br /> 5-30 Herr <br /> Cm STATE ZIP <br /> STbcaETon CA Q <br /> Mailing Address WDIFFERENT from Facility Address Attention:or Care Of(optional) <br /> 7'ke Tw.�r'.g jobs,^o%o.ies Lie.. 2-5-27 yr/'C5-- STieeT Vein 6e-,1na7T <br /> Mailing Address City STATE uP <br /> F�cs�a C-A- 9'3 7Z <br /> �`rr 7. f a ; w 3 ✓ . <br /> "i5' .fir -,.0 A•y.Lr. �t :,'� <br /> N. tl hYfit .:�' rw z — A � �' r rv`'�y <br /> THIRD PARTY BILLING INFO: Completeif Billing Party is different from Property Owner or Facility Operator identified above. <br /> BUSINESS NAME <br /> I Attention:or Care Of (optional) <br /> T�E Tw ;ni n aiooraTorie s TnL Vern U vtvlC-r!t <br /> ��dress PHONE <br /> ,2527 Frt svt� STreeT (s'S9)ZGY-7ozl <br /> CrT STATE zip <br /> Fre srlo CA 9372/ <br /> ACCOUNTADDREM for fees and Charges OWNER FACILITY/BUSINESS THIRD PARTY BILLING <br /> BILLING AND COMPLIANCE ACKNOWLEDGNTENT: I,the undersigned Applicant,certify that I am the Owner,Operator,or Authorized Agent of this Business,and I acknowledge that all PER-WT FEES, <br /> PEN tLITES,ENFORCEMENT CHARGES and/or HOURLYCHARGES associated with this operation will be billed to me at the address identified above as the ACCOL7vrADDRESs for this site. I also certify that all <br /> information provided on this application is true and correct; and that all regulated activities will be performed in accordance with all applicable SAN JOAQUN 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 DIVISION as soon as it is available and at the same time it is provided to <br /> me or my representative. <br /> PLEASE PRINT <br /> APPLICANT NAME /� SIGNATURE �'� Q <br /> 0�dU �lc(/y.E ! iQ' fes, <br /> TITLE / (PHOTOCOPY O 0 REQUIRED ) <br /> Approved By . Date Accounting Offfea.Ptueesstng Complryy <br /> t Ni 10EN" 1 A <br /> L <br /> f <br />