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San Joor- County Environmental Health Oartment <br /> DATE <br /> GREEN FORMjUSL8am2(_ MASTER FILE RECORD INFORMATION "MFR" <br /> CNe �nnaFe <br /> OWNER ID# <br /> `ASE# UNIT IV <br /> OWNER FILE <br /> COMPLETE THEFOLLOWING PROPERTY OWNER INFORMATION; CHECKIF OWNER CURRENTLYONFIIEWmf EHD <br /> PROPERTY OWNER NAME _ �Tj (, <br /> PHONE �CJq /�. 1 7 1`--// q I <br /> First Ml Last <br /> BUSINESS NAME C <br /> , :C() L -SOCSEC/TAxID# N� 4 <br /> Owner Home Address n <br /> DRIVER'S LICENSE# N/A <br /> City <br /> STATE ZIP <br /> PM.N.1'EgAddress <br /> ing Atldress I O <br /> City State CA Zip clF, cv10.7 <br /> TUFF nc nwNFuwm <br /> CORPORATION❑ INDIVIDUAL❑ <br /> PARTNERSHIP❑ FED AGEnLY❑ <br /> OTHER❑ <br /> C/20 1`J6 , 5-0(D ---76-7 FACILITY FILE Qoau LA <br /> FAa7ID# j'5 CROSS.RE,ID# ACCOUNT ID# INY# n 1 7 <br /> f 7 <br /> 0mim"Mr-OLIOWING EACILrTY SITE &EQRMAZWN° G{ <br /> Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ No 6C1 <br /> IS this an E%ISRNG Business LOCATION but a NEW TYPE Of regulated Business? YES ❑ No m <br /> Bti$INESS/FACILITY/SITE NAME orm V r Unocal 4 -`509- <br /> SITE ADDRESS a`/^ <br /> �.{�jc� -�-r �C�C.1-�I i✓ >`t�IL,.YI Vf�' SUITE# BUSINESS PHONE <br /> CITY C7 �yx.�` 11 STATE G,T / <br /> ZIP �l (� —r <br /> BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEv1 �,2 f / <br /> Mailing Address ifDIFFERENTham Favi/ityAddress / Attention:or Care Of(opdona/) 1 <br /> Ta 1< rcxrm d2e,. �rC)s3cx � � i 4e;lLir�SC� C J1 <br /> Mailing Address City Cj��1 L�15 CY01 rS }7o STATE CA ZIP <br /> SIC CODE APN# �I _7 <br /> COMMENT: <br /> THIRD PARTY BILLING INFO- Complete if Billing Party is different from Property Owner or Facility Operator identified above. <br /> BUSINESS NAME n <br /> Attention:orCa a Of (opt/on 0 <br /> Mailing Address I C�vT� Old P l Q( &ru i e_ omd 8r✓r,'. H�r�in � bore <br /> PHONE C <br /> ll(p 31p� 71 OC <br /> c Tamen+o D r y s STATE CA ZIP C/SR D-7 <br /> A=QuNLAnneg9F for fees and charges OWNER <br /> FACILITY/BUSINESS T DPARTY BILLING <br /> B r : 1,the undersigned Applicant,certify that 1 am the Owney OPeratoy or Authorized Agent of this Busin $S', ¢ I kn <br /> wlNlg at all PERMIT FEES, <br /> PENALTIES,ENFORCEMENT CHARGES and/Or ROURGYCHARGES associated with this operation will be billed to m¢at the address identified above a5 the APmpM gnnNecc <br /> for This site. 1 also eerfifyanal all <br /> information provided on this application is [rue and correct; and that all regulated activities will be performed in accordance with all applicable SAN dOAQU1N COUNTY Ordinance <br /> dinance Cates 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 authariz¢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 e' <br /> provided to me or my representative. same is/ <br /> APPLICANT NAME (�ef,LiL7v ✓rte PLEASE PRINT <br /> TITLE SIGNATURE <br /> /� <br /> (PHOTOcROP RREOUIRED) <br /> E;;Z etl BY Date Accounting Office Processing Completed BY D to <br /> 29-02-002 April 25,2003 <br />