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San Joaquin Coupfy biic Heaith',Servicb Environm ),Health.Division <br /> GREEN FORM <br /> DATEFE=_ <br /> MASTER FILE RECORD INFORMATION "MFR" <br /> SHARED AREAS FOR EHD a3e ONLYO'Wry°ER ID# . UNIT IV <br /> OWNER FILE <br /> COMPLETE THEFOLLOW/NG PROPERTY OWNER INFORMATION.' CHECRIF OWNER CURRENTLY ON FILE WITH EHD ❑ <br /> PROPERTY PHONE <br /> OWNER NAME <br /> Fist MI last <br /> BUSINESS NAME SOC SEC I TAX ID# <br /> Owner Home Address DRIVER'S LICENSE# <br /> City <br /> STATE Zip <br /> Owner Mailing Address <br /> Mailing Address City State Zip <br /> CORPORATION'El INDIVIDUAL M PARTNERSHIP El FED AGENCY Cl OTHER <br /> FACILITY FILE <br /> ,.., ._.OROS& r:r iD=ik'" ......::.... . ...-AceQUNTtiDi- <br /> COMPLETE THE FOLLOWING BUSINESS I FACILITY I SITE INFORMATION: <br /> Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DIVISION? YES ❑ NO ❑ <br /> Is this an EXISTING Business LOCATION buts NEW TYPE Of regulated Business? YES ❑ NO ❑ <br /> BUSINESSIFACILITYISITE NAME <br /> SITE ADDRESS SUITE# BUSINESS PHONE <br /> CITY STATE ZIP <br /> IBOARD'OFSUPERVISOR_ ( LOCATION I c') KEY} I <br /> Mailing Address WDIFFERENTfrom FacilityAddress Attention: or Care Of(optional) <br /> Mailing Address City STATE ZIP <br /> SIO CODE APIC# ,.. COMMENT[ <br /> THIRD PARTY BILLING INFO: Complete if Billing Party is different from Property Owner or Facility Operator identirfedabove. <br /> BUSINESS NAME Attention: orCare Of (optional) <br /> Mailing Address PHONE <br /> CITY STATE Zip <br /> ACCODNTADDRESS fOf fees and Chafges OWNER FACILITY/BUSINESS THIRD PARTY BILLING <br /> BILLING AND COMPLIANCE ACKNOWLEDGMENT: I,the undersigned Applicant,certify that I am the Owner,Operator,or Authorized Agent of this Business,and I acknowledge that all <br /> PERM/TFEEy,PENALT/EV,ENFORC'EMENTCHARC,EV and/Or ffOURL Y CHARGEV associated with this operation will be billed to me at the address identified above as the AC'COUN%ADUNF_Ky <br /> for this site. I also certify that all information provided on this application is true and correct;and that all regulated activities will be performed in accordance with all applicable SAN <br /> JOAQUIN COUNTY Ordinance Codes and/or Standards and STATE and/or FEDERAL Laws and Regulations. As the undersigned owner,operator,or agent of the property located at the <br /> above facility/site address, 1 hereby authorize the release of any and all results and environmental assessment information to SAN JOAQUIN COUNTY ENVIRONMENTAL. <br /> HEALTH DIVISION as soon as it is available and at the same time it is provided to me or my representative. <br /> PLEASE PRINT <br /> APPLICANT NAME SIGNATURE <br /> DRIVER'S LICENSE# <br /> TITLE IPHOTOOIIVV NPOUIRFin <br /> -i. A"otihting OfticeiProa6ss}ng CoRipletedB <br />