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San JO*in County Environmental Healthtpartment <br /> DATE CASE GREEN FORM <br /> MASTER FILE RECORD IrvFORMA(INFORMATION "MFR"nfRr' <br /> e.............. .eanr.r..... OWNER ID# IJ.L � �..:. <br /> UNIT IV <br /> OWNER FILE <br /> COMPLETE THEFOLLOWINGPROPERTY OWNER INFORMATION; CHEcwrF OWNER CHRRENnyoNFnEwTnv <br /> PROPERTY OWNERPHONE <br /> ( ' .S <br /> x <br /> NAME 7 <br /> First MI heat <br /> BUSINESSNAMEC Soc Sec/TA%ID# <br /> Owner Home Address) /w w, u 'l-Etsf/ DRIVER'S LICENSE At <br /> city 6L f'i-/_ STATE Z[P <br /> Denver Mailirp Address <br /> Mailing Address City r� r� State Zip <br /> rIIOMYaIfn _ TNM1MMIEI I 1 O�piucp[u,ol FCn nI:GNIY❑ IMHFYI 1 <br /> FACILSTY ID# CROSS REF ID# � �F:,(� r` ✓1 r 1 ACCOUNT ID# a �� Q�� Eis INv# <br /> 71hsthis1,NEM1STrN1 <br /> E THEF LL WIN d,"t NF RMATI — <br /> a EW Business LOCATION not previously regulated by the ENVIRONMEWAL HEALTH DEPARTMENT? YES ❑ NO ❑ <br /> Business LOCATION but a NEW TYPE of regulated Busing 7 YES ❑ No ❑ <br /> BUSINESS/FACILITY/ <br /> 0 L p.,� tnti <br /> v L <br /> SITE ADDRESS sum# BUSINESS PHONE <br /> � � IS n�r7 <br /> I �! '�Zo <br /> CITY �'1 �(. �" rvf�._ STATE ZIP <br /> IIBOARD OF SUPERVISOR DTstrau I I LOCATIONCODE I M ( �(EYL I KEYZ <br /> Mailing Address ifDIFF£RENrltron Facility Address Attention:or Care Of(optional) <br /> Mailing Address City .STATE ZIP <br /> 1 SIC CODE _ - APN# COMMENT: - <br /> (THIRD PARTY BILLING INFO; Complete if Billing Party is different from Pro rty Owner or Facility Operator identified above. <br /> BUSINESS NAME O� ('/�1 O! 1 1 T P,&.14 <br /> ttenNO :ofCaR (OP60/Id/) <br /> Mailing Address r7 D f2 o x i4q o1.�o Jti/•-fl-V I'v PHONE <br /> 61 Cut <br /> DIY 14nA "l�Kr -�74o -gLjooTE zip <br /> ACCOUNTADDOFCC for fees and charges OWNER FACILITY/RUSINESS THIRD PARTY RILLING <br /> HILLING INf.INn CONIP1 IANC[ACEN 1 " ; I,the undersigned Applicant,Cerdfv that I am the(Ironer,Operator,or Authorized Agent of this Business,and 1 acknowledge that all PERAfrT FEES, <br /> PENALTIES,ENFORCEMENT CHARGES and/or HOORLYCHARGES associated with this operation will be billed to me at the address identified above as the ACrnynT ADDRicc 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,I 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 to me or m}representative. <br /> PLEASE PRINT <br /> APPLICANT NAME SIGNATURE <br /> TITLE DRIVER'S LICENSE# <br /> (PHOTOCOPY REQUIRED) <br /> Approved BY Date T1 Accounting Office Processing Completed BY (� �.. . Dube > 123, `l <br />