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3ifiy1�hi3fcesEi� iotiiinealth Division <br /> GREEN FORM <br /> DATEMASTER FILE RECORD INFORMATION "MFR" <br /> ry'yy UNIT IV <br /> HADED AREALFOR EH D U9€ONLY �wN�IlJii �.a rs`^CA6E � t"'2a�is o�,` <br /> D� -5 Y� - OWNER FILE <br /> COMFLETETHEFOLLOW/NG PROPERTY OWNER INFORMATION: CHECK/F OWNER CuarrENrt roNFaEwirHEHD <br /> PROPERTY PHONE <br /> OWNER NAME <br /> First M/ Ms( <br /> BUSINESS NAME ^ SOC SEC/TAX ID# <br /> Owner Home Address DRIVER'S LICENSE# <br /> City - -- STATE ZIP <br /> Owner Mailing Address !—)—7 <br /> Mailing Address City C� State� Zip '9 <br /> CORPORATION❑ INDIVIDUAL❑ PARTNERSHIP❑ FED AGENCY❑ OTHER <br /> ' ,0 FACILITY <br /> FILE <br /> COUi t v" '1A!11Sa*1;zee rod:, :, 777771 <br /> COMPLETFTHEFOLLOW/NG BUSINESS /FACILITY/SITE INFORMATION: <br /> Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DIVISION 7 YES ❑ NO ❑ <br /> Is this an EXISTING Business LOCATION but a NEW TYPE of regulated Business 7 YES ❑ NO ❑ <br /> BUSINEss/FACILITY/SITE NAME 1 <br /> SITE ADDRESS SUITE# BUSINESS PHONE <br /> 4 -ia kir►-►rv>,� �rJ <br /> CITY A j -- <br /> €_... I §yT{r <br /> tE FZIP <br /> 7- <br /> 1;r'-7— :� leID Ua <br /> I. II <br /> Mailing Address/fD/FFERENTfrom Facility Address Attention: or Care Of(optional) <br /> Mailing Address City STATE ZIP <br /> *+ <br /> 1 a �YIV t � bI�IM itf * M� a� a sw° s a r 1 7 r z <br /> THIRD PARTY BILLING INFO: Complete if Billing Party is different from Property Owner or Facility Operator identified above. <br /> BUSINESS NAME � � ^ �L�CI Attention: or Care Of (optional), <br /> 1' l U✓d- t � u'—^ <br /> Mailing AddressL V Q PHONE G (9 a <br /> CITY ,i STATE A'<i ZIP � Z Z-! z.Z <br /> ArcoUNTApORES-s for fees and charges OWNER FACILITY/BUSINESS THIRD PARTY BILLING <br /> BILLING AND COMPLIANCE ACKNOWLEDGMENT: 1,the undersigned Applicanl,certify that I am the(honer,()perator,orAuthor/zed Agent o nwledge that all <br /> PERM?FEES,PENALnF_v,ENFORCFAfF.NT Cl/ARGEC and/or 110URLYCHARGES associated with this Operation will be billed to me at the address Identified above as Ilse AccoUNTAVDRESS <br /> for(his site. 1 also certify that all Information provided on this application Is true and correct;and that sill regulated activities will be performed in nccordimce w'lth all applicable SAN <br /> JOAQUIN COUNTY Ordinance Codes and/or Standards and STATE and/or FEDFRAL Laws and Regulations. As the undersigned owner,operator,or agent of the properly located nl the <br /> above facility/site address, 1 hereby authorize the release of any and all results and environmental assessment Information to SAN JOAQUIN COUNTY E VIRONMENTAL <br /> HEALTH DIVISION as soon as It is available and at the same lime it Is provided to me or my representative. / <br /> PLEASE PRINT <br /> APPLICANT NAME �f' r/ SIGNATURE <br /> TITLE /////J w' - DRIVER'S LICENSE# N Z <br /> (PHOTOCOPY REGI IIREL1 <br /> k JY�` <br /> 'Y.� qfqW-00- �"'�� <br /> l <br />