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San Joaquin County Environmental Health Department <br /> GREEN FORM <br /> DATE *"MFR" <br /> MASTER FILE RECORD INFORMATION <br /> rNAMDRFAZ FQR PHn SE N1Y OWNER ID# CASE# <br /> I .......... ............ UNIT IV <br /> OWMER FILE <br /> COMPLETE 77m FOLLOwING PROPERTY OWNER INFORAM 770N., CHEcKiF OWNER CuRREffaroN FxLE WrtH EHD <br /> PROPERTY OWNER NAME PHONE <br /> First M1 Last <br /> BUSINK-NA!.- So('LICITIXID# <br /> L4 S <br /> e f <br /> d <br /> Owner Home Address DRIVER'S LICENSE# <br /> Cly STATE FIya 0-( A-,- <br /> Owner Mailing Address r <br /> Mailing Address City State (l,t� Zip <br /> -Fy 113 ely-I <br /> TYPF nF AwNFPcm <br /> CORPORATION❑ INDrVIDUAL 0 PARTNERSHIP FED AGENCY El OTHER El <br /> FACILITY FILE <br /> ............ <br /> FACILITY ID T-C—Ro"'REF I.D # 1 ACCOUNT ID# INV# <br /> ComxvF rHE FoLL OWING B ACILITY .1 SlTi 1111FOR—MA 7-T-O---Sw <br /> Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ No ❑ <br /> Is this an EXISTING Business LOCATIyl I <br /> ON but a NEW TYPE of regulated Business? YES ❑ No ❑ <br /> BUSINESS fFAcxuTY/SIT-.NAME -, ' '. <br /> IL <br /> Srre ADDRESSSUITE# BUSINESS PHONE <br /> 0 SOA V�i'1Y, <br /> CITY STA InZIP <br /> BOARD OFSuPERvisoR DISTRICT LOCATION CODE KEYl KEY2 <br /> Mailing Address ffDrFFERENTfrorn AxIWAddress Attention:or Care Of(optional) <br /> Mailing Address City STATE ZIP <br /> SIC CODE APN# �'COMMENr: <br /> THIRD PARTY BILLING INFO- Completed Billing Patty is different froln Property Owner or Facility Operator identified above. <br /> 13USINESS NAME Attention:ot-Ware Of (optfonal) <br /> Mailing Address PHONE <br /> CITY S ZIP <br /> A=Wr-4Pujmv5 for fees and charges OWNER FACILITY/BUSINESS THIRD PARTY BILLING <br /> BILLING AND COMPIJANCE ACKNOWI,FwGilaymr: I,the undersigned Applicant,certify that I am the Owner,Operator,or Authorized Agent of this Business,and I acknowledge that all PE]afr!'FEE-S, <br /> PLIAAL17EY,ENFOI?CEllfCATCHARGES and/or HouR1,YCHAf1GF5 associated with this operation will he billed to meat the address identified above as the ACCOONTADDILE.C,P 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 bi 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,I hereby authorize the release of <br /> any and all results and environmental assessment information to SAN JOAQUIN COUNTY FNVIRON14ENTAL HEAL'rH DEPA"NT as soor�ps it is available and at the same tin 'it is <br /> provided to me or my representative. 7 <br /> APPLICANT NAME PLEASE PRINT SIGNATURE <br /> 4. <br /> Z' <br /> TITLE DRIVER'S LICENSE# <br /> fPHOTOCOPY REOUIRED) <br /> jApproved By Date Accounting Office Processing Completed By Dat, <br /> 29-02-002 April 25,2003 <br />