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San Joaquin my Environmental Health Depart nt <br /> l <br /> DATE GREEN FO RM <br /> 7/0 _l MASTER FILE RECORD INFORMATION AxMFR" <br /> //��.• (/ OWNER ID# l tl G� ,!, It CASTS# <br /> UNIT IV <br /> OWNER FILE <br /> COMPLETE THE FOLLOWING PROPERTY OWNER INFORMATION; CHECKIF OWNER CURRENTIYON FILE WITH EHD <br /> -Ty �?3 <br /> PROPERTY OWNER PHONE _ <br /> NAME Ile s /V- <br /> First MI last <br /> BUSINESS NAME SOC SEC/TAx ID# <br /> Owner Home Address DRIVER'S LICENSE# <br /> city STATE zip <br /> Owner Mailing Address <br /> Mailing Address City 3 .2 — State, �j Zip <br /> DS� < <br /> TYDF nF nwNFCHiD �/ J <br /> rnDDnDSTTnN TNnrvrnllni GEDTNFDGHiD n FFn ArFNry❑ /YTMFD❑ <br /> ' \ kAb 1 56D <br /> FACILrry ID# CROSS REF IO# ACcouNT ID# INV# <br /> COMPLETE THEFOLLOWING BUSINESS I FACILITY SITE INFORMATION. <br /> Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES No ❑ <br /> Is this an E)as iNG Business LOCATION but a NEW TYPE of regulated Business? YES ❑ No ❑ <br /> BUSINESS/FACILITY/SITE NAME <br /> �Q H <br /> SITE ADDRESS SUITE# BUSINESS PHONE <br /> 3 �/ s �1 y /472� <br /> I <br /> F=Z3 ,Zs s <br /> CITY C / STATE ZIP <br /> / `( /y 5 <br /> BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEY l I _ I KEY2 <br /> Mailing Address if DIFFERENT from Faci/ityAddress Attention:or Care Of(optional) <br /> Mailing Address City STATE ZIP <br /> SIC CODE .; APN# COMMENT: <br /> THIRD PARTY BILLING INFO: Complete if Billing Party is different from Property Owner or Facility Operator identified above. <br /> BUSINESS NAME Attention:or Care Of (optional) <br /> Mailing Address PHONE <br /> CITY STATE ZIP <br /> ArY^nrte/T tit DREsQ for fees and charges OWNER FACILITY/BUSINESS THIRD PARTY BILLING <br /> Rit.t.ING AND Comm iANcF ACKNnwiLDenIFNT: 1,the undersigned Applicant,certify that 1 am the Owner,Operator,or Authorized Agent of this Business,and 1 acknowledge that all PER,tnTFEEs, <br /> PENALTIES,ENFORCEMENT CHARGES and/or 11OLIRLYCHARGES associated with this operation will be billed to me at the address identified above as the ACCOICYT.ADARESS 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/site address,1 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 /> PLEASE PP <br /> APPLICANT NAME S'T�ti SIGNATURE <br /> TITLE `J T�N DRIVER'S LICENSE# <br /> S �— (PHOTOCOPY REQUIRED) <br /> �F1PV�ld « 'Date . _ Accounting Office Processing Completed By .. Date L1 <br />