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San Joaquin County Environmental Health Department <br /> DATE L�'�F� D MASTER FILE RECORD INFORMATION ""IFR" GREEN FORM <br /> QwAnFn ARFA<Fm FHn nsFntu V - UNIT IV <br /> OWNER FILE <br /> COMPLE7F7NE FOLLOWING PROPERTY OWNER INFORMATION: CHECKIF OWNER CVRReNrzroHF"WrrH EHD <br /> PROPERTY OWNER NAME PHONE <br /> First MI Last <br /> BUSINESS NAME SOC SEC/TAX ID# <br /> Owner Home Address DRIVER'S LICENSE# <br /> City STATE ZIP <br /> Owner Mailing Address 23 7 7t / <br /> Mailing Address City f r�O State <br /> MteE nF OwmmmnD L <br /> CORPORATION❑ INDMDUAL❑ PARTNERSHIP❑ FED AGENCY❑ OTHER❑ <br /> FACILITY FILE <br /> .ter3ID# CROSS REF ID# ACCouNr ID# _ INv# <br /> FcILITY <br /> i <br /> COMPLETEE LL WIN RMATI m <br /> Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES No ❑ <br /> Is this an E)asTING Business LOCATION but a NEW TYPE of rpgulated Business? YES ❑ No <br /> Btfs>rlEss/FAmm/SITE NAME Gi / i I� J �IGlb-ries <br /> ' SITE ADDRESS SUITE# BUSINESS PHONE <br /> clrY tJ STATE � �3 0 `7 <br /> Mailing Address ifDIFFERENTfrom Fac/l/tyAddress Attention:or Care Of(optional) <br /> Mailing Address City STATE ZIP <br /> THIRD PARTY BILLING INFO: Comp/ete if Billing Party is different from Property Owner or Facility Operator identified above. <br /> BUSINESS NAME Attention:orCare Of (options/) <br /> � /lit c� /yJ. 5Go7�/�f)9�lS�oIGT <br /> [Mailing Address /�/)D/ �91 /_ /,., <br /> FP—E ��� <br /> Flt/ (J(Q tL/ <br /> CITY C �/CJ_ __- w- STATE/ /, ZIP <br /> ear n,wr enDREys for fees and charges OWNER FACILITY/BUSINESS THIRD—PARTY BILLING <br /> Rn.I IN('.AND CONIPIJANCF ACKNOWLFD(:NIFNT: 1,the undersigned Applicant,certify that I am the On-ner,Operator,or Authorized.4gent of this u al ell PERdIITFEES, <br /> PENALTIES,ENFORCEMENT CHARGEN and/or HOURLYCHARGES associated with this operation will be billed to me at the address identified above as the ACCOUATADpRFSC for this site. 1 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,1 hereby authorize the release of <br /> any and all results and environmental assessment information to SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTNIENT as soon as it is available and at the same time it is <br /> {)rovided to me or my representative. 0 <br /> PLEASE PRINT `wfC/1 "I/�C� <br /> APPLICANT NAME SIGNATURE <br /> TITLE DRIVER'S LICENSE# <br /> (PHOTOCOPY REQUIRED) <br /> Approved By Date Accounting Office Processing Completed By Date <br /> 29-02-002 April 25,200 <br />