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4 <br /> GREEN FORM <br /> DATE <br /> MASTER FILE RECORD INFORMATION "MFR" <br /> OWNER ID# CASE# <br /> 13 UNIT IV <br /> OWNER FILE <br /> COMPLETE THE FoLL o wiNG P RO P E RTY OWNER INFORMATION; CHECKiF OWNER Cu)7REffnyoNFzLE wrTHEHD <br /> PROPERTY OWNER PHONE <br /> NAME <br /> First MI last <br /> BUSINESS NAME C- F Cw ty\s Soc SEC/TAx ID# <br /> Owner Home Address 33 , , 14 U DRrVER's LICENSE# <br /> city -P 56 <br /> ZIP <br /> Owner mailing Address <br /> Mailing Address City State Zip <br /> TYPF ru,nywNFRIHTP <br /> P— <br /> F,&('ILI= Fill 5: <br /> sFACIim ACCDLWT ID# <br /> REF ID# <br /> ID R'I <br /> COMPLL N F LLMA T70N.' <br /> Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES El No El <br /> Is this an E)aSTING Business LOCATION but a NEW TYPE of regulated Business? YES El No 0 <br /> BUSINEss/FAciLrry/SrTE NAME F-c" YY <br /> SITE ADDRESS L C- SUITE# BUSINESS PHONE <br /> CITY 4b STAJA_ 21P <br /> Mailing Address WDIFFERElyrflum FacilifyAddress Attention:or Care Of(optional) <br /> Mailing Address City STATE zip <br /> sic com- COMMEJ# <br /> THIRD PARTY BILLING INFO: Completeif Billing Party is different from Property Owner or Facility Operator identified above. <br /> BUSINESS NAME Attention:ot-Care Of (optional) <br /> x e--�-- G e- Ll e V111 I <br /> PHONE <br /> [M�rmgAdd res' 3 C4 <br /> 4 7� STATE ZIP <br /> AccomrADDREss for fees and charges OWNER FACILITY/BUSINESS THIRD PARTY BILLING <br /> Rn I ING AND CL15 LEEK.NIFNI: 1,the undersigned Applicant,certify that I am the Owner,Operator,or Authorized Agent of this Business,and I acknowledge that all PER,wr FEES, <br /> PENALTIES,ENFOR==A,'.djor HOURLYCHARGES associated with this operation will be billed to me at the address identified above as the AccorrNT ADDRFCC for this site. I also certify that all <br /> information proNicled on this application is true and correct; and that all regulated acti%ities will be performed in accordance with 211 applicable SAN JOAQUIN COUNTY Ordinance Codes and/or <br /> Standards and STATE and/or FEDERAL Laws and Regulations. <br /> a e i W 'IRAP711EEtY97tt HEAL7ITT5 RTMENT time i" <br /> priiiided-ta me or rnLjgpLosnjaa�ir-- <br /> PLEASE PRINT <br /> APPLICANT NAME SIGNATURE <br /> DRIVERS LICENSE#TITLE LVicit- IDV6 KA/� <br /> I~TOCOPY REOUIRED) Date <br /> ApprovedIly Date Accounting Office Processing Completed By <br />