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C Envif,6Hffi, Al Health,Division <br /> GREEN FORM <br /> DATE MASTER FILE RECORD INFORMATION "MFR" <br /> SHADED AREAS FOR EHD usE ONLY VN ��� ��A-{'/�^�'_ UNIT IV <br /> NO <br /> OWNER FILE <br /> COMFLETE THEFOLLOWING PROPERTY OWNER INFORMA T1W.- CKIF OWNER CURREAfrLYOA1F1LEW1rEHD <br /> PROPER lz-'e'S�6 . <br /> ly-4V Am at- <br /> 772 -T' PHONE <br /> OWNER NAME CD G4' <br /> Fk$1 Mt <br /> BUSINESS NAME SOC SECA.IDy <br /> &rkmA-ee- OONS*rvc�A e <br /> Owner Home Address 10500 DRIVER'S LICENSE# U60L 52—2-3 <br /> City ry-ewl � eltlm i� A STATE z'1P q5,2 ol <br /> Owner M.Mnq Ada. o.. <br /> Mailing Address City OX 1 I 1 6�+,D ki State OA '7 <br /> - C1 zip 6 00 <br /> CORPORATION <br /> TYPF nF nwmFRqHjP INDIVIDUAL❑ PARTNERSHIP❑ FED AGENCY OTHER 0 <br /> = <br /> FACILITY FILE A QE 4 <br /> 141 <br /> 7'41N <br /> o W,MOKIR-o' 6 0 uk"i 16'g <br /> COMPLETE rHEFOLLowINGBUSINESS If FACILITY/SITE INFoRmA 7-IoN.- <br /> Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DIVISION 7 YES El No d <br /> Is this an EXISTINc.Business LOCATION but a NEW TYPE of regulated Business 7 YES 0 No/ <br /> BUSINESS/FACILITY/SITE NAME <br /> SITE ADDRESSSUITE 111 BUSIN SS HONE <br /> --Ie'duc- 61V"I. c) LIAL <br /> CITY STATE zip �0 <br /> 6o <br /> K F" <br /> MAWR MR. <br /> Re, <br /> Mailing Address If DIFFEREN7-from FacifityAddress Attention:or Care Of(optional) <br /> Mailing Address City STATE zip <br /> P <br /> THIRD PARTY BILLING INFO: Completed Billing Party is different from Property Owner or Facility OperaV*-')G�6 ed above. <br /> ij'ECEIVED <br /> BUSINESS NAME Attention: or Care Of (qptionP) - <br /> 1 SRI 2 ID <br /> Mailing Address PHONE <br /> SAN JUAQUIN U:�:] <br /> STATE P C HEALTH SERVICES <br /> CITY <br /> ENVIRONMENTAL HEALTH DIVISION <br /> AC-CPVArAVJVR1E55 for fees and charges OWNER FACILITY/BUSINESS THIRD PARTY BILLING <br /> III LIANG AND COM PLIANCE Aci<NOWLF.I)G MEN r: 1,the undersigned Applicant,certify flint I note(lie Owner,Operator,orAuthorized.4genforthis Business,need I Acknowledge flint All <br /> rf.,-RA(rr FFF-V,PFIv.4L riEy,E1vr0RCFAfr1VT CIfARGF-T and/or flouRi.I,Cn.4RCF-V Associated with this opera(to"will fee billed tome R(the Address Identified Above As flee ACCOUNTADnRFC5 <br /> ror this site. I also certify that all Information provided on this Application Is(rue and correct;and that nil iegulated Activities will he performed in Accordance iii(h all applicable SAN <br /> JOAQUIN COUNTY Ordinance Codes and/or Standards and S rA IFF And/or FEDERAL LAWS and Regulations. As the undersigned owner,operator,or agent of(lie property located At(lie <br /> Above facility/site Address, I hereby authorize the release of any And All results need environmental Assessment Inrornia(lon to SAN JOAQUIN COUNTY ENVIRONNIEN'IAI, <br /> IlEAL'I'll DIVISION as soon as It is Available and at the same time it Is provided to me or my representative. <br /> PLEASE PRINT <br /> APPLICANT NAME Del-rie"w Dever&,4-x, SIGNATURE <br /> I DRIVER'S LICENSE-1 <br /> TITLE 0-4 S A 4-4A-4t� fPHQTQCQPYflEWlIRFn-1 bo L(,S'2- 2 <br />