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San Join County Environmental Health Department <br /> All <br /> GREEN FORM <br /> DATE MASTER FILE RECORD INFORMATION " <br /> SHADED AREAS FOR EHD USE ONLY OWNER ID# CASE# UNIT IV <br /> OWNER FILE <br /> COMPLETE THEFOLLOWING PROPERTY OWNER INFORMATION: CHECKIF OWNER CU\RRENTLYONFILEWITH EHD ❑ <br /> PROPERTY OWNER NAME PHONE COW ! \ 6 8 30 00 <br /> First MI Last J v <br /> BUSINESS NAME SOC SEC/TAX ID# <br /> San J'Oa vI n CDVr1 <br /> Owner Home Address ED VER's LICENSE# <br /> 1810 Em, auk f ailGmuc <br /> city -i.pc on STATE Cq ZIP 9533'0 <br /> Owner Mailing Address �"�IV(jj�U <br /> FNV1Hu�1141EN i hE State Zip <br /> Mailing Address City <br /> P d4FQV19�] <br /> F <br /> CORPORATION❑ INDIVIDUAL❑ PARTNERSHIP❑ FED AGENCY❑ OTHER❑ <br /> FACILITY FILE <br /> FACILITY ID# CROSS REF ID# ACCOUNT ID# INV# <br /> COMPLETETHEFOLLOWING BUSINESS/FACILITY/SITE INFORMATION: <br /> IS this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPT.? YES ❑ NO ER <br /> Is this an EXISTING Business LOCATION but a NEW TYPE Of regulated Business? YES ❑ No <br /> BUSINESS/FACILITY/SITE NAME W h i to SID I W r+Lrr Pp l (/' ,oA C-.. r0) c, oi 4!`,A W e� <br /> SITE ADDRESSav►S I 1 �� r Q.L y SUITE# USINESS PHONE <br /> CITY a 1 STATE ZIP <br /> BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEY1 KEY2 <br /> Mailing Address ifDIFFEREAT from FacilityAddress Attention:or Care Of(optional) <br /> Mailing Address City STATE ZIP <br /> =SICCODE APN# [COMMENT: <br /> THIRD PARTY BILLING INFO: Complete ifBilling Party is different from Property Owner or Facility Operator identified above. <br /> BUSINESS NAME i� r I )' Attention:orCare Of(optional) <br /> V ( L Opl, <br /> Mailing Address �) ,_1 L �In� S� PHONE 'a09) 333_ oo0 <br /> CITY �O v I W STATE vQ` ZIP 9!s& 0 <br /> 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 PERWT FEES, <br /> PENALTrES,ENFoecEmENTCRARGFs and/or HouRLYCAARGEs associated with this operation will be billed to me at the address identified above as the ACCOUNTADDREss 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 /> �-1I _ PLEASE PRINT a <br /> APPLICANT NAME �M SIGNATURE <br /> TITLE �\ S �, �n DRIVER'S LICENSE# <br /> T � (PHOTOCOPY REQUIRED) <br /> Approved By Date Accounting Office Processing Completed By Date <br />