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San *uin County Environmental Heal*epartment <br /> GREEN FORM <br /> DATE MASTER FILE RECORD INFORMATION "MFRrr <br /> ...... ........nm ..,v,. OWNERID# o(3vog'. :. CASE# UNIT IV <br /> OWNER FILE <br /> COMPLETE THE FOLLOWING PROPERTY OWNER INFORMATION: CHECNIF OWNER CURRENTLY ON FILE WrTN EHD El <br /> PROPERTY OWNER PHONE <br /> NAME �`O Luc ic e y 175-6el <br /> First Mt last <br /> BUSINESS NAME SOc SEC/TAX ID# <br /> � TCN � r�rPs <br /> Owner Home Address i 75. rtMK}}ykLe j PLd' DRVeER•S LICENSE# <br /> .0 • box 3I0 <br /> l <br /> city La ll%,Vf <br /> STATECa JI zip 0/15--33 <br /> Owner Mailing Address Pd 3Oic 3./C) /-r <br /> Mailing Address City V St-t-G/} Zip 95-330 <br /> TYPc n[nw ERSLI <br /> fnoonenn /Tunnnfnu7(u1 I Dno.v[ocmo n /�p� 11 Fcn Atcury n rin•cn I I <br /> FAQLm'ID# ,'w I 5-vp CROW REP ID# `ACCOUM ID`# <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 ❑ No ❑ <br /> BUSINESS/FAQIITY/SITE NAME <br /> TC� <br /> SITE ADDRESS Sum# BUSINESS PHONE <br /> 1-7 A 1 5, Ma 'ALAI e k <br /> C[TY IfYL t 6A 53✓ STATE MP <br /> BOAM OP SUPERWSOR DISTRTa ..I' TION CODe I ' KEY3 " ..': •.. }. I KEY2 I II <br /> Mailing Address if DIFFERENTrrom Facility Address Attention:or Care Of(optional) <br /> Mailing Address City STATE LP <br /> :SIC CODE' .`= APN#`".'- t= ;.,� .:. }'; � ` - COMMvrt:-"-':, '`1 •+:I s ;� , .a <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 /> �P1GEo Snc . / <br /> Mailing Address ZBpI N �� (3(V�- e _ 3 PHONE ZU9 <br /> Cm 0O <br /> 'CA <br /> LP ,ASH S b� <br /> Tc*=� <br /> AcCouNFADDAESS for fees and charges OWNER FACILITY/BUSINESS THIRD PARTY BILLING <br /> 1,the undersigned APPlicant,certify Out(]am the owner,OPeroror,nr Au/horiz d Agent of(his Business,and I acknowledge(hat all PERanT FFFJ, <br /> PENALTIES,ENFORCAMENTCHARG£S and/or HOURLYCHARGFs associated with this operation will lx billed tome at the address identified above as the ACCD/IATADORFGC 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 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 as it is available and at the same time it is <br /> provided(o me or my representative. <br /> PLEASE PRINT <br /> APPLICANT NAME 7—Q G e� cQ( 1,2. J�' " SIGNATURE <br /> TITLE �/- 6 /eO,O t ! 1 l DRIVER'S LICENS <br /> Approved By Date :Accounting Office Processing Completed By Date <br />