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r ` J <br /> San Joaquin County Environmental Health Department <br /> GREEN FORM <br /> DATE MASTER FILE RECORD INFORMATION "MFR" <br /> QNAnrn.RFACFria FH n IKF nNI v L I I I UNIT IV <br /> OWNER FILE <br /> COMPLETETHEFOLLOWINGPROPERTY OWNER INFORMATION; CHEGYIF OWNER CURRENrzYONrILEWrrH EHD <br /> PROPERTY OWNER NAME PHONE <br /> First Ml Last <br /> BUSINESS NAME SGC SEC/TAx ID# <br /> Owner Home Address DRrvEWs LICENSE# <br /> City STATE ZIP <br /> Owner Mailing Address <br /> Mailing Address City State Zip <br /> TYDF QF flWNFRt{RD <br /> CORPORATION❑ INDIVIDUAL❑ PARTNERSHIP❑ FED AGENCY❑ OT/ER❑ <br /> FACILITY FILE <br /> FACRITY ID# CROSS REF ID# ACCOUNT ID# INV# <br /> COMPIMTHEFOLLOW.MG BUSINESS I FACILITY I SITE INFORMAUON.' <br /> Is this a NEw Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT. YES ❑ No ❑ <br /> Is this an EiasnNG Business LOCATION but a NEW TYPE of regulated Business? YES ❑ No ❑ <br /> BU.SDIESS/FAmITY/SrLE NAME <br /> SITE ADDRESS SUITE# BUSINESS PHONE <br /> CITY STATE ZIP <br /> Mailing Address ifDIFFERENrfrarn FacilityAddress Attention:or Care Of(optional) <br /> Mailing Address City STATE ZIP <br /> THIRD PARTY 13ILLING INFO: Completed Billing Party is different from Property Owner or Facility Operator identifiedabove. <br /> SUSME.SS NAME Attention:or Care Of (optional) <br /> Mailing Address PHONE <br /> CITY STATE ZIP <br /> er rnlnurdnnRcce fbr fees and charges <br /> OWNER FACILITY/BUSINESS THIRD PARTY BILLING <br /> BILLING AND COMPI.IANrF ACKNOWI.FIN:MFNT: 1,the undersigned Applicant,certify that I am the Owner,Operator,or Authorized Agent of this Business,and I acknowledge that all PERMtr FE£s, <br /> PENALTIES,ENFORCEMENT CHARGES and/or HOURLYCHARGES associated with this operation will be billed to me at the address identified above as the ACCOUNTADORECC for this site. I also certify that <br /> all 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 my representative. <br /> APPLICANT NAME PLEASE Pani( <br /> SIGNATURE <br /> TITLE DRIVER'S LICENSE# <br /> (PHOTOCOPY REQUIRED) <br /> APproi'ed By De. Acmu tdng Ofnee Processing Completed By Date <br /> 29-02-002 April 25,2003 <br />