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an JoF In County Environmental Health y iartmen , <br /> r 9 <br /> DATEL / / GREEN FORM MASTER FILE RECORD INFORMATION ��MFR" <br /> c�e�on eo..c rno FHn ,c�tw,v OWNER ID#' q UNIT IV <br /> OWNER FILE <br /> COMPLETE THEFOLLOWINGPROPERTY OWNER INFORMATION; CHECK IF OWNER CURRENTLYONFILE WITH EHD E <br /> PROPERTY OWNER PHONE <br /> _(?� <br /> NAME 0o r y�v�"" /may <br /> /' --3 y�� <br /> First MI last <br /> BUSINESS NAME SOC SEC/TAx ID# <br /> Owner Home Address /Z/ / DRIVER'S LICENSE# <br /> •/ GC yto <br /> City y,u C STATe,,,.` ZIP <br /> Owner Mailing Address <br /> Dov t <br /> Mailing Address City State Zip <br /> TYPF nF nwNFR^CHTP <br /> rrlD Dr�D OTir1N 1. I TNr�MrlllEl DGDTNLp CHiD I 1 FFh AI:FNN 1 I (}TyeFp LI <br /> FACILITY ID# " �` CROSS REP ID# r 'ACCOUNT ID#.... 7! INV# i <br /> COMPLETE THEFOLLOWING BUSINESS I FACILITY I SITE INEORM4TION. <br /> Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ No <br /> Is this an E)aSTTNG Business LOCATION but a NEW TYPE of regulated Business? YES ElNo <br /> BUSINESS/FACILITY/SITE NAME <br /> SITE ADDRESS / SUITE# BUSINESS PHONE <br /> r o a1/1� 1��T/ /"G C�� ,lam <br /> CITY <br /> rc< < , <br /> STATE Zip <br /> - <br /> BOARD OP SUPERVISOR DISTRICT J I LOCATION CODE I I � �hh fXEY I <br /> q <br /> KaR <br /> Mailing Address ifDIFFERENTfrom Faci/ityAlddress Attention:or Care Of(optional) <br /> 1/ 5.a <br /> Mailing Address. STATE ZIP 7r <br /> IL <br /> S /p <br /> F1sIC CODE ... Am,", p�i�gi` { Pig <br /> ■l��ll�l 'g� COMMENT:.... � § <br /> THIRD PARTY BILLING INFO: Complete if Billing Party is different from Property Owner or Facility Operator identified above. Qp <br /> BuslNEss AME Attention:or Care Of (optional) <br /> (i'-SPU �! f-e- �!d! �•f Pyr <br /> Mailing Address PHONE <br /> Waj <br /> J� 05 <br /> QTY TIG TD � <br /> errnirntr dnngccc for fees and charges OWNER FACILITY/BUSINESS THIRD PARTY BILLING <br /> RII.I lN(-.'ANI)('ONIPI[tNCF ACI<Nosvl t-nrnrervT: 1,the undersigned Applicant,certify that 1 am the Owner,Operator,or Authorized Agent of this Business,and I acknowledge that all PERMIT FEES, <br /> PENALTIES,ENFORCEMENT CHARGES and/or HOURLYCHARGES associated with this operation will be billed tome at the address identified above as the ACCOUNT AI)IMESC for this site. 1 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 PRINT <br /> APPLICANT NAME /�O SIGNATURE <br /> TITLE }� �! DRIVER'S LICENSE# <br /> f PHOTOCOPY REOUIRED) <br /> jL Approved By Date Accounting Office Professing Completed BY is Date � '., <br />