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San quin County Environmental Health _ _partment <br /> GREEN FORM <br /> DATE MASTER FILE RECORD INFORMATION "MFR" <br /> CHanFn an FEC Fon FHn I IsF()Ni V OWNER ID# F <br /> CASE# UNIT IV <br /> OWNER FILE <br /> COMPLETE THE FOLLOWING PROPERTY OWNER INFORMATION. CHECK IF 0WNERCmaRENTLYONFILE wrTH E H D <br /> PROPERTY OWER-NAME (_ U-e.,j dRa L,..J PHONE t y t(' — 11$.�^ 3 4q <br /> '~'.j :- 'iFirst M/ Last ( — _ �3 1411 L{ <br /> // V <br /> BUSINESS NAME [ 0 U - S SOC SEC/ AX ID* 33 +O 3 19` 9 <br /> Owner Home Address 0 / .�� /s A -Q tff.,DRIVER'S LICENSE# 0 (-jr <br /> n�5 <br /> city ,1;,.,r�, s�ATE Z-P��1�aG� <br /> Owner Mailing Address <br /> Mailing Address City State Zip <br /> CORPORATIONS INDMDUAL❑ PARTNERSHIP❑ FED AGENCY❑ ymmo <br /> FACILITY FILE <br /> FAm 7# � CROSS REF ID# AccouNT ID# INV# <br /> OMPLETE THE FOLLOWING NFORMATION' <br /> Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ No <br /> Is this all EXISTING Business LOCATION but a NEW TYPE Of regulated Business? YES ❑ No <br /> BUSINESS/FACILITY/SITE NAME VAR VC <br /> ' <br /> SITE ADDRESS HILSUITE# BUSINESS PHONE <br /> jLLz ri Y2.3 k7 <br /> CITYh STATE ZIP S 3 L <br /> BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEY1 K[YZ <br /> Mailing Address IfDIFFERENTfrom Faci/ifyAlddless Attention:or Care Of(optional) <br /> Mailing Address City STATE ZIP <br /> SIC CODE <br /> F <br /> PN# COMMENT: <br /> THIRD PARTY BILLING INFO: Comp/ete if Billing Party /s different from Property Owner or Facility Operator identified above. <br /> BUSINESS NAME �, / Attention:or Care Of (optional) <br /> AM, Eov tx, Li <br /> Mailing AddressI 60 -,J" /1 , a t 2U C 3 PHONE G l 1 t _g 7 t— <br /> CITY �/ 7 STATE _ ZIP <br /> A�-r nirarr A DARMS for fees and charges <br /> OWNER FACILITY/BUSINESS THIRD PARTY BILLING <br /> Hu r jw: %n('n%,-JAN(F ACKNOXX,rl-my%r: 1,the undersigned Applicant.certify that 1 am the Owner.Operator,or Authorized Agent of this Business,and I acknowledge that all PERAHTFEES, <br /> PhN fLTm.'s,EvroRCEhIC.vTC11ARc1-s and/or HOURLY CimRGES associated with this operation will be billed to me at the address identified above as the ArrnryT Annurcc for this site. I 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 JOAQLIN 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,1 hereby authorize the release of <br /> any and all results and environmental assessment information to SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon t is available and at the same time it is <br /> provided to me or my representative. PI FACE PRINT <br /> APPLICANT NAME 1..,.ARR Y Elk SIGNATURE 4 <br /> TITLE t1 - DRIVER'S LICENS 4t pef ifs l? 2- <br /> ri ',12 Ll QU�P rjlS� (PHOTOCOPY REOUIRED) <br /> Approved By Date Accounting Office Processing Completed By Date <br /> ''9-0''-00, April 25,2001 <br />