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San juin County Environmental Healtf - partment <br /> GREEN FORM <br /> Wr <br /> DATE W MASTER FILE RECORD INFORMATION "MFR" <br /> gDEDAREAEFORHD OSE ONLY OWNER IDR <br /> GER UNIT IV <br /> OWNER FILE <br /> pacwi OWNER(rYdtlbY7ErarHFlNff/EHD <br /> n � <br /> CoMpLETEEcto►wMc;PROPERTYOWNER/Ar.ORMnaw �Z3 _tea <br /> PRONE <br /> pROpERry OwrIER NAytE <br /> First MI Lost <br /> SINESS NAME <br /> ALL G BocsECITAaIDs 6 <br /> DRIVEp'B LICENSER <br /> Owner Home Address / '/(� STATE LF <br /> Cft <br /> 55 5 <br /> Ownv.Meiling Addree. /l 3 Z a Y�� �' " `� �— (f A IZ <br /> /� <br /> Mailing Address City Stan-C-�.WV✓t -�. ZIP{.o <br /> CORFatATIon❑ <br /> INDIVIDUAL <br /> PunxERSNn FED M3etcr❑ u�4' <br /> FACILITY FILE <br /> FACILITY ID R CROSS REF ID R <br /> Account ID R I Nv7t <br /> COMPLETE7H,i i BLOW IVO BUSINESS I FACILITY/SITE INfORMA17/0N' <br /> Is this a NEW Business LOCATION not pfeVlOUely regulated by the ENVIRONMENTAL HEALTH DEPTYEs [I No <br /> .? <br /> Cy <br /> Is this an EXISTING Business LOCATION but a NEW TYPE of regulated Business? <br /> YEs ❑ NO <br /> BLONESS FADILm1SRE NME M <br /> rtER BUSINEMPHONE <br /> SnEADDREsS <br /> rt <br /> STATE LP <br /> Cm � <br /> BOARD or SUPERVISOR DlsmwT <br /> LOCATION CODE KEY1 KEs2 <br /> At4antim:a Care Or(0111aBOwa) <br /> Melling Address 1rDIFF&TOVI'frwrr FeGNbAaldrew <br /> STATE ZIP <br /> Mailing Address City <br /> ICCOOE APNR COMMENT: <br /> T PARTY BILLING INFO: Complete ifBilling Party i ' erentfromProperly <br /> Owner orFacility Operator identified above. <br /> Attention:orC MS Of(OPNO q <br /> E <br /> PHONE <br /> Meiling Address <br /> STATE Zm <br /> Om <br /> M for fees and charges OWNER FACILITY/BUSINESS THIRD PARTY BILLING <br /> "D CameuANcE ACKNOWLFDGMENT: 1,the undersigned Applicant,Certify that I am the Owneq Oyer@or,or Authorized Agent of this Business,and t admowlthis that all P�unrFW' <br /> PEwAcnEs,EraF ESTrm'Cr ss and/or HOIMYCHARC associated with the operation wig be billed to me at the address identified above as the ACCouvrADnntSY for this site. t also ratify 1hs <br /> an information provided on this application is hue and rorreM and that all regulated activities will be performed in accordance with all appbCable Stn JOAQUIN COUTTry Ordinance Codes andb <br /> Standards and STATE and/or NEDF.RAI•Laws and Regulations. As the undersigned maser,operator,or agent of the property located at the above fadgtyhiie address.I hereby authorize the reJsie r <br /> any and all results and esvironmmhl assessment information to SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as f is available and at the same time it <br /> Provided to me or my representative• <br /> APPLICANT NAME PRINT <br /> I n�7 ,, I SIGNATURE <br /> TITLE ,��.� �=°• N — <br /> _ ORIVER•SuI cENISEX <br /> ���C�'J <br />