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. far RFs" Cin'jrfriaiiPainmentaHea[te�artr�tlent <br /> r gGREEN FORM�l � - AIS"" <br /> DATE � MASTER FILE RECORD INFORMATION "MFR" <br /> - <br /> a UNIT IV <br /> A# : <br /> OWNER FILE <br /> COMPLETE THE FOL LOWING PROPERTY OWNERINFORMATION: Ckrd F OWNER CURREMLyONmT HarrfEHD <br /> PROPERTYDYmER —1 PHONE <br /> NAME ]H\ <br /> First MI last <br /> BUSINEss NAME / ,w�i-1 a�/I/fJ(ys�Jfi/ SOC SEC/TAX ID At <br /> Owner Home Address S �1 r �. DUYER's Llo.NSE# <br /> city 15T79 ClF-rV STATE 04- 1 zip <br /> 4_ ZIP <br /> Owar Mailing Address <br /> Mailing Address City !–�irtrtifvl state Zip <br /> TVOF f1F rIYrMFGCMiO I—I <br /> r4tppnpptirw❑ Tunivrmoo OeetumWtn❑ FS,,,jom M.' lYrHco iJ <br /> red <br /> MPLETE THFFQLL0lVjAtG BUSINESS I FACILITY I SITE N <br /> I5 this a Nm Business LOoATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT-7 YES ❑ No ❑ <br /> Is this an EXISTING Business Lounois but a NEw TrPE of regulated Business? YES ❑ No ❑ <br /> BUSINESS/FA0LrrYISLTE NAME <br /> SITE ADDRESS Sum# BUSINESS PHONE <br /> �, SrAiE,A zip <br /> CrZ�F�F'�-.� <br /> Mailing Address ifDIFFERENTfrom FacilityAddimss Attention:or Care Of(optional) <br /> Mailing Address City STATE Zip <br /> APIt(fCAM, Ehl g* . <br /> w <br /> f <br /> THIRD PARTY BILLING INFO; Comp/ete if Billing Party is different from Property Owner or Facility Operator identified above. <br /> BusmEss NAME Attention:orCare Of (optional) �� <br /> kefS770 /J�/��Z/N[-� �tl� E7&-71C- 1)u <br /> Mailing Address 2 >Z.e�� A�� PHONE ,AGF �&Z —All'? <br /> "" �7✓G� STATE/ /I ZIP �SO J J <br /> Arras//sur AUDRICC for fees and charges OWNER FACILITY/BUSINESS THIRD PARTY BILL J <br /> gill IN,ANhr,,EI,IaNcF AfKNDwr Fnr.MeNT: 1,the undersigned Appliean4 certify Roof am the Owner,Operator,or Authorized Ageot of this Business,and I aclasowledge that all PERMIT <br /> PENALTIES,ENFORCEMENT CH"GEB and/or HOURLYCHARGES associated with this operation will be billed to meat the address identified above as the 4C VAT AnnReec for this site. 1 also certify <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 <br /> Standards and STATE and/or FEOEBAL Laws and Regulations. As the undersigned owner,operator,or agent of the property located at the above facility/site address,I hereby authorize the re <br /> any and all results and environmental assessment information to SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPA NT as soon as it is available and at the same ti <br /> provided to me or my representative. <br /> PLEASE PITTNr / <br /> APPLICANT NAME 5��!!�/T7 l/� ,/^J SIGNATUR S 1 ��J <br /> DRrVER's LICENSE# <br /> TITLE fpHomm"REQUIRED <br /> Approved By "Dale " Accounting Office Processing:oMPieted-,BY <br />