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• . " • <br /> San Joaquin County Environmental Health Department <br /> GREEN FORM <br /> DATE MASTER FILE RECORD INFORMATION "MFR" <br /> %autrin aara-Nm--num nNi" �7.6000 �tg UNIT IV <br /> OWNER FILE <br /> COMPLE7E THE FOLLOWING PROPERTY OWNER INFORMATION: CMEL-RIF OWNER CURRENTEVONFAE wmN END <br /> PROPER YOM RNAME PHONE LI 34 S <br /> First MI Last <br /> BUSINESS NAME ^ II, , 1D JI SOCSEC/TAKID# <br /> Owner Home Address �0 / -/ DRIVER'S LICENSE# <br /> CRY STATE ZIP <br /> Owner Mailing Address <br /> Mailing Address City State Zip <br /> r:rx nsuNrmm� <br /> CORPORATION❑ INDIVIWAL❑ PARTNERS UP❑ Fm AGENCY❑ OTHER❑ <br /> FACILITY FILE <br /> FACILITY ID At Irs, CROSS REF ID#.. ACCOUNt ID# `^ . INV# <br /> CommfmNG BUSINESS / FACILITY I SITE INFoRmA rr m uu <br /> Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ No ❑ <br /> Is this an BaSHNG Business LOCATION but a NEW TYPE of regulated Business? !rY�E✓Sl ❑ No ❑ <br /> BUSINESS/FACRItt/SITE NAME _ l WIC .0 <br /> SHE ADDRESS sum# BUSINESS PHONE <br /> CITY S ",^ STATE ZID o - ` <br /> Mailing Address ifDIFFFRENffran Fac/iityAola ess Attention:or Care Of(opthalaQ <br /> Mailing Address City STATE ZIP <br /> THIRD PARTY BILLING INFO: Comp/ete if Billing Party is different from Property Owner or Facility Operator identified above. <br /> BuSQNESS NAME Attention:scare Of (optionaQ <br /> Mailing Address .L-& —LS C- tNA♦ I ` (14 S� <br /> CITY [ 6e I . ua STATE eA ZIP 1 l a s^ <br /> AcoguaLAMitesc'for fees and charges OWNER FACILITY/BUSINESS THIRD PARTY BILLING <br /> I,the undersigned Applicant,certify that I am the Owner,Operator,or Auchoriwd Agenr of this Business,and 1 acknowledge that all PERNTf FEES, <br /> PEWirI ,ENEORCEMEMCHA ,es and/or HQUaYCHA Ev associated with this operation will be billed to me al the address identified above as the An' UMADDRECY for this silo 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 SANJOAQIIIN COUNT V 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 time it is <br /> gmvided to me or my representative. <br /> PLEASE PRIM <br /> APPLICANT NAME SIGNATURE <br /> Trnx DRIVER'S LICENSE# <br /> (PHOTOCOPY REQUIPEDI <br /> Approved BY Date ACCor-th"office Processing completed BY Date J J <br /> 29-02-002 April 25,2003 <br />