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San Joaquin County Environmental Health Department <br /> GREEN FORM <br /> DATE ' Q MASTER FILE RECORD INff �� , <br /> 5w. eeunn�.n..v OWNER ID# CI�?�7 1`— UNIT <br /> IV <br /> OWNER FILE MAR <br /> COMPLETE THE FOLLOWING PROPERTY OWNER INFORMATION; TH <br /> CHECKIF OWNER CuRREnrLroNFrLEtvrrHEHD <br /> PROPERTY OWNERlx�, ENV I / Ey�`r1Jr HHOONEE� <br /> NAME W _ 4 -J L,IL-Q/L/,{ lJ IJ�,J <br /> .]� First MI last <br /> a• <br /> NE NAMn SOC SEC/TAx ID# <br /> Owner Home Address J " ' DRIVER'S LICENSE# <br /> I ` , <br /> City STATE ZIP <br /> Owner Mailing Address3 3 11iL V.6 A�` <br /> / M, <br /> Mailing Address C' -f State Zip <br /> IrnDDnDeTTnN 1__1 TNnMnllsl r_1 VAOTNFO CNiD I I J�F FFn AY.CNr'Y 1._I /�THFD I_.I <br /> FAatm ID# g df2z CRoss REF ID# ACCOUNT ID# �Q� l INv# <br /> NF RMATION,' <br /> Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ No <br /> Is this an E)aSTING Business LOCATION but a NEW TYPE of regulated Business? YES ❑ No, <br /> BUSIN aLny S N <br /> SITE A DRESS /�/� SUITE# BUSINESS PHONE <br /> o <br /> CrYIODE <br /> STATE zipBOARDOPSUPERvLSORDISTRIcrLDI //n I KEYJI .,:;.. IKEY2 I II <br /> Mail' Address if DIFF Tfrom Fa zW' Add Attention:or Care Of(optional) <br /> a' rens ' STATE ZIP <br /> 4 <br /> 5 pyo <br /> SIC CODE APN# Commmr: <br /> THIRD PARTY BILLING INFO: Complete if Billing Party is different from Property Owner or Facility Operator identified above. <br /> BUSINESS NAME !? Attention:orCare Of (optional) <br /> Mailing Address PHONE <br /> CITY STATE Zip <br /> 4rentrtur4DDRESS for fees and charges OWNER FACILITY/BUSINESS THIRD PARTY BILLING <br /> RU.t Ivr.avn C'nnlvt l.vvrr. 4rl:vow•Lent:vlrv1: 1,the undersigned Applicant,certify that 1 am the Owner,Operator,or Authorized Agent of this Business,and I acknowledge that all PERMIT FEES, <br /> PE.V.�LTtES,E:YFORCESIE:VT CHARGES and/Or HO['RLY CHARGES associated with this operation will be billed to me at the address identified above as the ArrOt'vTAnDRF"for this site. I 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/si address,1 hereby uthoriu the release of <br /> any and all results and environmental assessment information to SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTv1Ey ass n it is availably'nd at the same time it is <br /> provided to me or my representative. <br /> PLEASE PRINT <br /> APPLICANT NAME—#/1,q SC SIGNATURE <br /> / DRIVER'S LICENSE# <br /> TITLE <br /> �� i (PHOTOCOPY REO,""ED) <br /> Approved By Date t Aotxwntirtg Office Processing Completed By Date <br /> 1 <br />