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ry San J - juin County Environmental Health r -iartment <br /> DATE �! �� R <br /> %01101rr GREEN FORM <br /> ! l MASTER FILE RECORD INFORMATION M <br /> tiADED AREAS FDR EHD Use ONLY OWNER ID# CASE# �IV <br /> OWNER FILE <br /> COMPLETE THE FOLLOWING P ROPERTY OWNER INFORMATION: CHECKIF OWNER CURRENTLYONFILEWn*H E H D ❑ <br /> PROPERTY OWNER NAME PHONE <br /> First M1 Last <br /> BUSINESS NAME ti SOC SEC/TAX ID# <br /> ti� ���cLt+� �tS <br /> Owner Home Address DRrVER's LICENSE# <br /> city STATE ZIP <br /> Owner Mailing Address j W O <br /> M WAY <br /> Mailing Address City Stat- ^ - Zip C <br /> fJ <br /> TYPE OF OWNERSHIP <br /> CORPORATION INDMDUAL❑ PARTNERSHIP❑ FED AGENCY❑ OTHER❑ <br /> FACILITY FILE <br /> faclLmID# rZ _j <br /> �ODO7YC �� <br /> 7T�Acc����� <br /> Aieo Inv# <br /> C0mPLErETHEFoLLoWING BUSINESS/ FACILITY/SITE INFoRmww : <br /> Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ No ❑ <br /> Is this an EXISTING Business LOCATION but a NEW TYPE Of regulated Business? YES ❑ No ❑ <br /> BUSINESS/FACILITY/SITE NAME <br /> SITE ADDRESS 1 SUITE# BUSINESS PHONE <br /> I3 n �. %.c.Jl c,sa/J CJ <br /> CITY STATE <br /> CA <br /> BOARD OF SUPERVISOR DISTRICT V LOC <br /> CODEI2 ` erJJ <br /> Mailing Address rfDtFFERENTfrom Fant Address Attention:or Care Of(opdonal) <br /> Mailing Address City STATE ZIP <br /> SIC CODE APN# COMMENT. <br /> 1ST Ozo� <br /> THIRD PARTY BILLING INFO: Complete if Biking Party is different from Property Owner or Facility Operator identified above. <br /> BUSINESS NAME Attention:or Care Of (optional) <br /> Mailing Address 12 fV/` , I 25 PHONE f lel q gG ' <br /> CITY. f [ <br /> STATE / , ZIP f/�� <br /> AccothyTADDBEss <br /> for fees and charges OWNER FACILITY/BUSINESS vTHIRD PARTY BILLING <br /> BILLING AND COMPLIANCE ACKNOWLEDGMENT: I,the undersigned Applicant,certify that I am the Owner,Operator,or Authorized Agent of this Business,and I acknowledge that all PERT FEES, <br /> PENALTIES,I±NFORCEMEAT CHARGES and/or floURLYCIlARGF„S associated with this operation will be billed to me at the address identified above as the ACCoUNLIPPRess 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 /> Standards and STATE and/or FEDF.RAL 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 ENVIRONMENTAL,HEALTH DEPARTM as soon as it is availahle and at the same time it is <br /> provided to me or my representative. <br /> APPLICANT NAME PLEASE PRINT <br /> y1` SIGNATURE <br /> TITLE A U4DjS TAX 11) <br /> (PHOTOCOPY REQUIRED) <br /> Approved Ely Date Accounting Office Processing Completed By <br /> 10_nrn A—N x Inns <br />