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Sanuin County Environmental Healt�epartment <br /> to GREEN FORM <br /> 1 DATE MASTER FILE RECORD INFORMATION "MFR" <br /> SHADED AREAS FOR EHD USE ONLY OWNER ID# T <br /> CASE#T —1 <br /> UNIT IV <br /> OWNER FILE <br /> COMPLETE THE FOLLOW/NGPROPERTY OWNER INFORMATION. CHEcKtF OWNER CURRENTLYONNFicewiTH EHD <br /> PROPERTY OWNER NAME PHONE t&09) 6V —3000 <br /> First MI Last <br /> BUSINESS NAME ��r _C1, __ SOC SEC/TAX ID# <br /> Scv� �P vin Ca�n� (� �j. <br /> Owner Home AddressI U I u1 r aS Z�1 �O h L DRIVER'S LICENSE# <br /> 1 O G <br /> City S t o c. !'o p t- STATE C(� zip 9 5 a 05 <br /> g <br /> Owner Mailing Address 16 4 I� HFALTH <br /> Mailing Address City state ZIP <br /> CORPORATION❑ INDIVIDUAL❑ PARTNERSHIP❑ FED AGENCY❑ OTHER <br /> FACILITY FILE <br /> FACILITY ID# CROSS REF ID#:1E ACCOUNT ID# IF <br /> INV# <br /> COMPLETE THE FOLLOW/NG BU SI N ESS/FAC I LITY/SITE INFORMATION.' <br /> IS this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPT.? YW0jW NOR <br /> IS this an EXISTING Business LOCATION but a NEW TYPE Of regulated Business? YES ❑ No K <br /> BUSINESs/FACILITY/SITE NAME W h I e, S j pV <br /> !1 1nfo,,fCr �Io tut,4n C,oh4ro) <br /> SITE ADDRESS O r / j�1 1 p _ 1 /a SUITE# BUSINESS PHONE <br /> Cm i � STATE ZIP <br /> BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEY1 KEY2 <br /> Mailing Address ifDIFFEREVTfrol"FaciiityAddress Attention:or Care OF(option/J <br /> Mailing Address City STATE ZIP <br /> =SICCO.E =APN# COMMENT: <br /> THIRD PARTY BILLING INFO: Complete ifBilling Party is different from Property Owner or Facility Operator identified above. <br /> BUSINESS NAME i (� 0 I I Attention:or-Care Of (option/J <br /> Mailing Address a I i n Si PHONE a,Oq 333 - 6800 <br /> Cm L-D R 1 STATE Cot ZIP 9sa yo <br /> AccoaNTAnnaEss for fees and charges OWNER FACILITY/BUSINESS THIRD 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 PERMHT FEES, <br /> PENALHEs,ENFORCEmHENTCHARGES and/or HOURLY CHARGES associated with this operation will be billed to me at the address identified above as the ACCOUNT ADDBESs 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 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 /> provided to me or my representative. <br /> APPLICANT NAME �.y �' PLEASE PRINT SIGNATURE OA,� <br /> via('\ a'w `--�. <br /> TITLE ( �^ DRIVER'S LICENSE# <br /> 1V3c �t t—C-/+ u'L-�.S 'V\7.��p�.�-'� (PHOTOCOPY REQUIRED) <br /> Approved By Date Accounting Office Processing Completed By Date <br />