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E � ..rr.- ...y _•-'_ i,Y�� y?' S."_..�. ,'O�-y-.-..._...y..-:�•.yRp ".y�'� gti-Y-.. <br /> �SaiA gUIn=County Env.��onmerital.Heal apartment <br /> GREEN FORM <br /> DATE "MFR" <br /> MASTER FILE RECORD INFORMATION <br /> a r F y 4,. �.:-:"�., t, •N.y t fir, 7 r hlw ■`A� <br /> .run,..rwn. �.✓QNfNEA ID# i' 4 t^."- ''^w' .r 3CASE#aro. r� ��4ygG"`�tkC't{. N� a �. UNIT IV <br /> '_t.RRiriJt�.atA'C'a..s '.�.:�^�r�.YS+ �fuYLbawa TM�t�J"SSWIAA.iu{� H.•ea .-d-'—r_..,_Y�tu <br /> OWNER FILE <br /> CHE[KIF OWNERCVRREHRYONFILEHrrTrtEHD ❑ <br /> COMPLETETHE FOCCOWYNGPROPERTY OWNER INFORMATION: <br /> PROPERTY OWNER PHONE <br /> NAME <br /> First Ml last <br /> BUSINESS NAME SOc 5E[/TAx ID#F <br /> Owner Home Address DR mFt's LICENSE# <br /> STATE ZIP <br /> city <br /> Owner Mailing Address <br /> State Zip <br /> Mailing Address City <br /> TYPE nE AWNvRgHTP <br /> Fen A rrwry❑ f1�++cP <br /> f noMoannN❑ TNn*�.�ni ui ❑ PenTMFacwra❑ <br /> r,,.. •:.:•.-., a. _ . <br /> tC.A s - y,,- •.,t; 1 Aa4� Y F *cs} "' 6 a'.:rINY# � �y s <br /> FACILITY ID#; .�.r '� 6a 055 REF YD#, a •N�.,.w': __ ..�fft`i- `Accattt+rrYD# ,;[. ^5�y,.�..::;•...:_....._.,..�: — -"f <br /> Fisis a NFYt Business LOCATION not previousiy regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ NO ❑ <br /> is an E7asriNG Business LOCATION but a NEW TYPE of regulated Business? <br /> YES ❑ NO ❑ <br /> BUSINESS/FACRXry/SITE NAME <br /> SUITE# BUSINESS PHONE <br /> SITE ADnRESS <br /> STATE XIP <br /> CITY <br /> 7-7 <br /> Fyia:hfT.wSr :'dr.. .KEY1•�ry ,:,iwa.`„-._ r'! ..� n_:a.-r_.:i , <br /> Attention:or Care Of(optional) <br /> Mailing Address if DIFFERENT from Facility Address <br /> STATE XIP <br /> Mailing Address CRY <br /> •y : .,< " - _ J'.±- K s, y'�� r ,y�,i-. R{y1 �'t-s-. .ti.pa.1 n...1.. `""�3:,s:...�m.�.rJ-a <br /> COI�N"tFHT� <br /> . <br /> :....: . re2c.iivs..r_:..'.,�eA.k�" iu1 + .:. <br /> SICCooE.�e.ri'-'_ �. <br /> Owner or Facility Operator identified above. <br /> THIRD PARTY BILLING INFO: Complete if Billing Pattyisdifferent from Property <br /> Attention:or Care Of (optional) <br /> BUSINESS NAME . <br /> iE <br /> PHONE <br /> Mailing Address <br /> STATE ZIP <br /> CITY <br /> wr�nrrurAr,nai:cC <br /> THIRD PARTY BILLING <br /> for fees and charges OWNER FACILITY!$USINESS <br /> 1,the undersigned Applicant,certify that 1 am the Owner,Operetor,or Authorized Agent of this Business,and I acknowledge that av PERtt7T FES' <br /> for this site. I also cerdfy that a <br /> pYALT!£S,EvFarrCf_trr-',T CH.tFGFS and/or FfoUltLvCxARGFSassociated with this operation will be billed to me at the address identified as the dCt:f#L:3Z8.QRBFSI <br /> information prodded on this application is true and correct,and that all regulated activities will be performed In accordance with all applicable.5A,j AQ UE COUN Ordinance Codes andlt <br /> Standards and STATE and/or FEDERAL Laws and Regulations. As the undersigned owner,operator,or agent or the property located at the above faciGtylsite address,I hereby authorize the release E <br /> mental assessment information to SA`JOAQUIN COUNTY E\YIRONNIENTAL HEALTH DEPARTMENT as soon 2S it is available and at the same time'[ <br /> any and all results and eosiron <br /> pr v,-&d to me or my representative. PLEASE PRD" <br /> SIGNATURE <br /> APPLICANT NAME <br /> DRIVER'S LICENSE# <br /> TITLE (PHOTOCOPY REOUIRED) <br /> P[OOes"+in9 CORtPietOd BY a cr�._�L:n`��z: °?a f�1 i SOatita�C y; - mss . �.:_ <br /> Approved SY= <br />