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San uln County Environmental Heal partment <br /> GREEN FORM <br /> DATE 3��F/ MASTER FILE RECORD INFORMATION "MFR" <br /> 'OWNERID# C,lSE# UNIT IV <br /> OWNER FILE <br /> COMPLETE THE FOLLOWING PROPERTY OWNER INFORMATION; CF/EcvzF OWNER LURRENTLYONFfLEwnHEHD <br /> PROPERWOWNER PHONE <br /> NAME <br /> Rat MI las! <br /> BUSINESS NAME SOC SEC/TAX ID# <br /> Owner Home Address DRNER'S LICENSE# <br /> City / STATE LP <br /> Owner Mailing Address <br /> '� l _..J v/op <br /> Mailing Address City State Zip <br /> NGF II[r1W [G�GIYIO 11 I''1— <br /> fnvonGeii x Tunrvrnxe, 1 Devix[GcuiG1 1 FGry GfiWN❑ 111H <br /> FAe'll I= Fill F <br /> FAaOrY ID# CRoss REF ID At I ACCouNT ID# DN# _ <br /> MP HE F WI RMA <br /> Is this a New Business LOCATION not previously regulated by the ENVIRONMEarru HEALTH DEPARTMENT. YES ❑ No <br /> Is this an EXIsTIxG Business LocainorIt,but a NEw TYPE of regulated Business T YES ❑ No LFu <br /> BUSINESS/FACL /SITE NAME <br /> SITE ADDRESS / SUITE# BUSINESS PHOx <br /> /G� 77-9,C S7- <br /> CITY SLATE zu, <br /> II ` rcr `u u I I I I I I I II <br /> BOARD OF SutNO[vlsoa DrlslRla LOCATIONCODE . KEYS KEr2 <br /> Mailing Address ifDIFFEREN T from Facility Address Attention:or Care OF(optional) <br /> Mailing Address City STATE ZTP <br /> THIRD PARTY BILLING INFO: Complete if Billing Party is different from Property Owner or Facility Operator identified above. <br /> BUSINESS NAME Attention:orCare Of (optional) <br /> Mailing Address PHONE <br /> Cm' STATE ZIP <br /> liocm/NT ADORIECC for fees and charges OWNER FACILITYIBUSINESS THIRD PARTY BILLING <br /> RiT i TNt,ANn Comps iANCE &CKNOR1 FOGMFNT: 1,the undersigned Applicant,certify that I am the Owneq Operator,or Authorized Ageul of this Business,and I acknowledge that all PERMIT FEES, <br /> PENALTIES,ENFORCEMENT CHARGES and/or NOUR£r CHARGES associated with this operation will be billed to me at the address identified above as the ACCOLINT ADDRESS for this site. 1 also certify that all <br /> information provided on this application is tree 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 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 ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same fime it is <br /> provided to me or my representative. <br /> PLEASE PRINT <br /> APPLICANT NAME SIGNATURE <br /> (^� c��\Dr�2� K1zrYx� ll L1 p l3'T�v + <br /> TITLE ,`r'e c=� r- C' [11 Vk-GS 1�4�v4'.(PIIRO OCAW REEQUIRED) <br /> Approved8v -Date AO nuiiA OfRce PruGessittg Completed By Date.. <br />