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San .',,aquin County Environmental Health ^epartment <br /> DATE GREEN FORM <br /> MASTER FI,LtE RECORD INFORMATION "'MFR" <br /> OWN1:R:1D# tt DISE# UNIT IV <br /> OWNER FILE <br /> COMPLETE THEFOLLOWING PROPERTY OWNER INFORMATION: CHECKIF OWNER CURRENTLYON FILE wITHEHD <br /> PROPERTY OWNER PHONE <br /> NAME <br /> Firs( MI la <br /> BUSINESS NAME 61 SOC SEC/TAx ID# <br /> Owner Home Address o DRIVER'S LICENSE# <br /> CnY Q1C STATE,;i ZIP <br /> Owner Mailing Address �,N /T / ham✓ <br /> Mailing Address City State_ Zip - <br /> TVPF nF nwNFRCHTP <br /> t'r DP DATTnN TNnr TnIIAI ❑ PAPT FPCHTD n <br /> FFA ArFNN n nTHFP <br /> 1olS'D3-0 �}QOL7256 (r <br /> tt , <br /> `FACILITY ID# CROSS REF ID# AccouNi ID# <br /> WI TION: <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 ElNo,D <br /> BUSINESS/FACILITY/SrrE NAME <br /> SITE ADDRESS SUITE# BUSINESS PHONE <br /> STATE zip <br /> BOARD OF SUPERVISOR DISTRICT I I LOCATION CODE I I KEY1 I _ I KEYZ <br /> Mailing Address ifDIFFERENTfrom Facility Address Attention:or Care Of(optional) <br /> o — , C> <br /> Mailing Address City / ` �, STATE Ztp , <br /> SIC CODE APN# COMMENT'. <br /> THIRD PARTY BILLING INFO: Complete if Billing Party is different from Property Owner or Facility Operator identified above. <br /> BUSINESS NAME Attention:or Care Of (optional) <br /> Mailing Address PHONE <br /> GoG� C'-r /° <br /> CITY SrAC�_ ZIP 95-(57:o -60.Z/ <br /> ArrnuATrdnnvccc for fees and charges OWNER FACILITY18USINESs THIRD PARTY BILLING <br /> RILLING AND C'(1MPI.IANrR.ArKNnwi.ynrmyNT: 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 /> PENALTLES,ENFoecEAmNTCA4RGES and/or HOURLY CHARGES associated with this operation will be billed to me at the address identified above as the ACCOI)NT ADnFF.CC for this site. 1 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 JOAQUIN COUNTY Ordinance Codes and/or <br /> Standards and STATE and/or FEDERAL Laws and Regulations. As the undersigned owner,operator,or agent of the properly located at the above c' inze the release of <br /> am and all results and environmental assessment information to SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPART)\ dI of �Ie same time it is <br /> provided to we or my representative. L <br /> PLEASE PRINT <br /> APPLICANT NAME SIGNATURE <br /> � �✓ tit - � V.� <r��. <br /> TITLE DRIVER'S LICEN <br /> C (PHOTOCOPY REOUI � f , <br /> Approved By fit_ 171 Date f� Accounting Office Processing Completed By Date3, <br />