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San uquin County Environmental Health epartment <br /> GREEN FORM <br /> DATE MASTER FILE RECORD INFORMATION "MFR" <br /> Si a Fn ewcec FnR FHA ucF nw v <br /> UNIT IV <br /> OWNER FILE <br /> CHECKIF OWNER CuRREryrcroNFILE WITN EHD <br /> COMPLETHE FOLLOWING PROPERTY OWNER INFORMATION; <br /> TE <br /> PROPERTY OWNER NAME (� PHONE L� <br /> First <br /> ��`--- MI Last <br /> BUSINESS NAME "' 454&6— <br /> zip <br /> SOC SEC I TAX ID## <br /> DRIVER'S LICENSE <br /> JOwner Home Address cityL " <br /> J/ <br /> Owner Mailing Address 0 \, L <br /> � 1 t <br /> Mailing Address City Stat > ZIP ` r LI <br /> TYPE r1F(IWNFRCHTD <br /> CORPORATION❑ INDMDUAL❑ <br /> PARTNERSHTPX FED AGENCY❑ OTHER❑ <br /> FACILITY FILE <br /> Act DUNrID# INV# <br /> FACILITY ID# CROSS REFID# - <br /> ComPETE THE F LLO NFORMATION' <br /> Is this a NEW Business LOCATION not previously/regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ No <br /> Is this an EXISTING Business LOCATION but a NEW TYPE of regulated Business? YES ❑ No <br /> BUSINESS/FACDXfY/SITE NAME <br /> .. f SUITE# BUSINESS PM <br /> SITE ADDRESS <br /> STATE ZIPr <br /> crty <br /> Mailing Address ifDIFFERENTfrorn Faci/ityAddress Attention:or Care Of(optional) <br /> Mailing Address City STA ZIP < dO/--j <br /> THIRD PARTY BILLING INFO: Complete if Billing Party is different from Property Owner or Facility Operator identified above. <br /> Attention:or Care Of (optional) <br /> BUSINESS NAME <br /> PHONE <br /> Mailing Address <br /> STATE ZIP <br /> Cm <br /> d�r•n AAirdnnRFcc for fees and charges OWNER FACILITY/BUSINESS THIRD PARTY BILLING <br /> Rn t mr Nn trontPt�nNCe Ctrwnwt t'nrmeN`r; I,the undersigned Applicant,certify that I am the(honer,Operator,or Authorized Agent of this Business,and I acknowledge that all PERMITFEES, <br /> PEVAL77ES,EJFORCFAIENT CHARGES and/or HOURLY CHARGES associated with this operation will be billed tome at the address identified above as the ACCO NTADDRESS 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 a it is <br /> provided to me or my representative. 1 J t <br /> PI FeCF� SIGNATOR `�- <br /> APPLICANT NAME G U '40 f / <br /> TITLE fI � <br /> f D# I�,!' O V— 0091 /� 2 <br /> Approved By Date Accounting Office Processing Completed BY Date <br /> t� <br /> 29-02-002 April 25,2003 <br />