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08/29/2005 15:08 2094683433 EHD PAGE 02 <br /> N, <br /> ;ftt h:� 13irtiRd.�M-O'Bi <br /> DATE GREEN FORM <br /> MASTER FILE RECORD INFORMATION "MFR" <br /> Z. <br /> -ca <br /> UNIT IV <br /> OWNER FILE <br /> COWLEZr TUE 0WAVEROPERTY OWNER ZVORMA77DN.' CXEDCLF OWNER C1JRNEffaYVNf3UWnNEHl) <br /> PROPERTY OWNER PHONE <br /> NAME Tnr< K LAF, 7-Oct (c <br /> JLV rear <br /> BUSXNESS NAME SOC Sec IT"ID# <br /> Owner Home Address DKVERS UCENSE# <br /> city STATE ZXP <br /> Owner Mailing Addrea <br /> Mailing Address City <br /> 7YPF no r1w. <br /> Frn Ar.pmry❑ cryugo❑ <br /> FEE W&AZLOWNG Fj1K-9TNFSS FACTI ITY I SJU 1AffVMAZW <br /> Is this a NEW Business LorATIorl not previously regulated by the ENVIRONMEWAL HEALTH DEPARTMENV yes 11 No <br /> Is this an Excmw Business LOCATION but a NEW TYPE of regulated Business? yes El No <br /> LPi <br /> BUSINESS/FA <br /> vvarz/� <br /> Srre ADDRE55 skump Busno-va PHONE <br /> crry STATE zw <br /> M—N I <br /> Mailing Address ifD1FFrREVT*"1b&rjtyAddre= Attention;or Care OfCap traw/) <br /> Mailing Address City STATE ZIP <br /> TWIRD pA1RTY BTL 1.tNG INFO; Complete if Billing Party is diterent hbm Property Owner or Facility Operator.identified above. <br /> Mailing Address PHONP <br /> k-re- I I to. 2S 7- <br /> 5TATE CA z'P 6(E-=H4 ?- <br /> Aa221ffiq=AQ29&w for fees and charges OWNER FAcury/BusimEss THIRD PARTY BILLING <br /> R11 I TNr-&NQ COMPI FANCP ACKNOWLynGMENT: 1,the underlipud Applicant,certify that I 2m ib*Ownw,Operator,orAulkarkedAgem of this Baines,and I acknowledile that all PERNIrFws, <br /> DWAALTIES,ENFORCEMCNY CHAW&Y and/or H0uRLrCHAfiG6S associated with this operation will be billed to me at the address Ideodfied 2bowas the Arry-wrAppausA for this site. I also certify that all <br /> zdbratation provided an this applicadon is true and correct:and that all regulated 2ctivida will be performed in accordance with all applicable SAN JOA011IN COON'Y Ord;mncv Codes and/or <br /> Standards and STATr,11ffld)0r FEDERAL Laws and Reguladoes. As the undersigned owner,operator,or agent of the property located at the abPV4:ficillty/sIte address,I hereby authorise the release of <br /> my and all results and environmental assessment information to SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same dme it in <br /> novided to me or my representative. <br /> PLVAbE PR11Wr <br /> APPLICANT KAMIE C SIGNATU <br /> TITLE < <br /> ct Ute OV <br /> In <br />