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San Joaquin County Environmental Health Department <br /> DATE !� GREEN FORM <br /> U � �� MASTER FILE RECORD INFORMATION "MFR" <br /> UNIT <br /> OWNER ID# DO// /a CASE# UNIT IV <br /> OWNER FILE <br /> COMPLETE THEFOLLOWING PROPERTY OWNER INFORMATION; CHECKrF OWNER CQRRENTLFONFILEWr EHD <br /> PROPERTY OWNER ^� <br /> NAME on 1 .e'3� e6/f PHONE <br /> a001 - 014 - 8:? Gq <br /> Fat MI last <br /> BUSINESS NAME SOC SEC/TRX ID# <br /> Owner Home Address O I ^ 'Qo � 1 DRIVER'S LICENSE# <br /> City /1 '' �1 p r� d <br /> W , I /h n h m SrA ZIP 6 1 6 8 /`^�DO <br /> Ownb Mailirp Address <br /> Mailing Address City P <br /> / J ✓� state ` z; � <br /> Noc nc rlw f� I—I rl <br /> fnoonoennu Tun{{(XM N,/o.,r❑ <br /> tl 1 Deoiumaure 1 [j�{j Fcn ECo/ury 1 (}nrco I..1 <br /> Perxm Tl)ft i roncc D=r In AryMnrt Tn. O rJ INN# �( - <br /> MP E TN "L <br /> N f A V <br /> IS this a NEw Business LOCATION not previously regulated by the ENVIRONMENTAL IIEALIH DEPARTMENT? YES ❑ No,9 <br /> Ls this an EXISTING Bus;ness LOCATION but a NEW TYPE of regulated Business T Yes ❑ No <br /> BUSINESS/FALL /SITE NAME <br /> Un + trt � � 6rar� ��o �1 <br /> SITE ADDRESS <br /> � SUITE At BUSINESS PHONE <br /> CRY STATE zip <br /> C 4 ( S--,)G <br /> IiEusugo PSUPERVISORDISTRIe'r I I Loaurrona CODE I I IDD(I I I KEY2 I II <br /> Mailing AddressYDIFFEREIYTBom Fac/dtyAddress A do :or Care Or tional) <br /> Mailing Address City SYG 4 �.n in STATE CAP <br /> SIC CODE � APN# COMMEM: <br /> THIRD PARTY BILLING INFO: Complete if Billing Party is differentfrom Property Owner or Facility Operator identified above. <br /> BUSINESS NAME Attention:or Care Of (optional) <br /> Mailing Address PHONE <br /> Cm STATE zip <br /> dr'rnr9q Aa=Es: for fees and charges OWNER FACILITY/ROSINESS THIRD PARTY BILLING <br /> Rr I,the undersigned Applicant,certify that 1 am the Owner,Operator,or Authorized Agent of this Business,and I acknowledge that all PEamiT FEES, <br /> PENALTIES,ENFORC£MEWCNARGES and/or HOURLTCHARG£S associated with this operation will be billed tome at the address identified above as the ArCouyr AanRFCc for this site. 1 also certify that all <br /> 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 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 resulb and environmental assessment information to SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH D ENT as soon as it liflatile and at the same time it is <br /> provided to me or my representative. <br /> PLEASE PRINT , J <br /> APPLICANT NAMEI SIGNATURE 4tf1(/\J <br /> TITLE &'>(f �C.. I I sr 1 L✓,i. <ei 1� DRrVER'S LICENSE# <br /> 1 (PHOTOCOPY REQUIRED)_ <br /> Approved By Date AMIL Accounting Office Processing Completed By Date �" O <br />