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^ . <br /> ^ ^ %%Mo/ <br /> Sari JumquinCounty Environmental Health Department <br /> I GREEN FORM <br /> DATIH MASTER FILE RF(101-011 INFORMATION <br /> 11 1 SITE MITIGATION& 1-01" <br /> OWNER ID11 —1 <br /> OWNEP, FILUN.COMPLETE-rmi-IrOLLOWIAIG PROPERTY OWNER IWORNATION.' CitEcielF OWNER CuRnENTI.VONFILEIVIV,L140 F] <br /> City STATE ZIP 2105 <br /> MallinUAddress City ";,at. 2ip <br /> -TR 7 Ro—ti ASSIGNED —IiWQCBE11TS f EPA <br /> Is I-Iiis a New Business LOCATION not pl'eViOLISly regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES 0 No El <br /> Is thisoo EXISTING Business I-ocAT(oN but a NrwTYPE of regulated Business? Yr.s 0 No El <br /> Crly <br /> BOARD OF SUPERVISOR DISTRICT LOCATIONCODE I<EY2 <br /> Mailing Addross City SFY <br /> ZIP <br /> T1111VID PARTY DILLINO UNPO: C0117/-7/&1e if Billing Patty is cliffereid fromPi-operty Owner-orFacility Opet-ator identified above. <br /> CITY ZIP <br /> AccouNrADDRE.q.-s for fees and charges OWNER FACILITY/BUSINESS THIRD PARTY BILLING <br /> IIII.I.ING AND('0111411m <br /> F"VI'mu Vor Ill I"billed III"'cal IhvmIdI-*S id-tifird;,II—c a,0w.-y cw-.vrjm,w-'xv for thi,Ate. I alm-er,[if,that <br /> ,ill i,f,,rmmiw, I Mc,j o,,[i,isappli,mi I,tru-10 011.ICI;: I that 1 ret,"Im"lac(hili" ,ill 1"1-1 ol in accord.-ce I ill,;,It appli-bl,SM10AOCIN COI.SfYo.dinwIc,0,d— Vor <br /> p~^w ~,""". o° <br />