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San Joaquin County clic Health Services Environmeno ealth Division <br /> GREEN FORM <br /> DATE Q /I_ t,l MASTER FILE RECORD INFORMATION "MFR" 11 <br /> axeoeR ansae FOR EHuuO use Oxo L� `OWNER ID# CASE#` VNIT IV <br /> OWNER FILE <br /> CNECM IF OWNER CURRENTLYON FILE WITH EHO II/I <br /> COMPLETE THEFOLLOW/NG PROPERTY OWNER INFORMAT/ON: LJ <br /> PHHO,N(/E�/{/�]� <br /> OWNER NAME <br /> FYY MI We <br /> D is So S I TAXI <br /> I D� <br /> BUSINESS NAME Ib��/fv, /lJ — /'�`M�JI-� / /,1�I1� <br /> D� DRIVER'S LICENSE# FV Ll f DTI, <br /> Owner Home Address 1111 ��Ll 1 <br /> City C 1 /1 STATF ZIP <br /> �4 <br /> Oner Mailing Address <br /> State <br /> Mailing AddftY D Zip t <br /> k <br /> - <br /> FED AGENCY❑ OTME <br /> CORPORATION❑ INDIVIDUAL C1PARTNERSHIP❑ <br /> FACILITY FILE ZI <br /> FACILITY ID#. : <br /> CROSS REF ID# I ACCOUNT to# INV# <br /> COMPLETE THEFOLLOWING BUSINESS FACILITY I SITE INFORMATION: <br /> Is this a NEW BDSIn¢S$LOCATION n0[pr¢vI0U51y regulated by the ENVIRONMENTAL HEALTH DIVISION? <br /> VES ❑ No;y,�, <br /> VES E] No <br /> Is this an EXISTING Business LOCATION but a NEW TYPE of regulated Business? <br /> BUSINESS/FACILITY/$ITE NAME I � <br /> SUITE# BUSINESS PHONE <br /> SITE ADDRESS <br /> STATE ZIP <br /> CITY <br /> BOARD OF SUPERVISOR <br /> 1 I LOCATIONCODE I I KEY1 I I KEY2 <br /> Mailing Address it D/FFERENT from Facility Address <br /> Attention:or Care Of(optional) <br /> STATE ZIP <br /> Mailing Address City <br /> SIC CODE.. . APtt If COMMENT: 1.. <br /> THIRD PARTY BILLING INFO; Completed Billing Party is different from Property Owner or Facility Operator identified above. <br /> Attention:orCare Of (optional) <br /> BUSINESS NAME <br /> PHONE <br /> Mailing Add e <br /> STATE ZIP <br /> CITY <br /> sees <br /> ACCOUNTADORESS for fees and charges OWNER FACILITY/BUSINESS THIRD PARTY BILLING <br /> BILLING AND COMPLIANCE ACKNOWLEDGMENT: 1,the Undersigned Applicant,certify that I am the Owner,Operal0r,or Author/fed Ageal of this Business,and 1 acknowledge that all DERV/T FEES, <br /> PE.YALNEV,ENF(Lw EMENTC ytorEV and/or ROURLYCNARCES assodated with this operation will he billed tome at the address identified above as the ACCOUNTADORE4S for this site. I also certify that <br /> all 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 /> operator,or agent of the roe located at the above facility/site/site address,1 hereby authorize the release of <br /> Standards and STATE and/or FEDERAL Laws and Regulations. As the undersigned owner, p g property rtY h <br /> any and all results and environmental assessment information to SAN JOAQUIN COUNTY ENVIRONNIENTAL HEALTH DIVISION as soon as it is availib andat the same time it is provided to <br /> me or my representative. <br /> / IV �PLEASE P IN; <br /> AU SIGNATURE <br /> � `/7`�•1,f�4/) <br /> APPLICANT NAME YV/I/, T <br /> DRIVERS LICENSE <br /> # (, <br /> �� <br /> TITLE r <br /> (PHOTOCOPY REQUIRED) <br /> Approved By Date <br /> —==Acounting Office Processing Complete Date <br />