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San Joaquin County Environmental Health Department <br /> GREEN FORM <br /> DATE Z�f 0� MASTER FILE RECORD INFORMATION "MFR" <br /> GUGr,F,GRF,S FnA FFIn IICF nN.V OWNER ID# CASE# UNIT IV <br /> OWNER FILE <br /> COMPLETE THE FOLLOWING PROPERTY OWNER INFORMATII N; r 11 / CHEcKiF OWNER CURREIVTLYom FILE WrrH EHD <br /> PROPERTY OWNER NAME { t,.{1�� -2 PHONE �IS ��^ rJ <br /> First M1 Last 4 <br /> 0 .J <br /> BUSINESS NAME JE u c fldcL Lkly -46L4r'j CAL'l <br /> SOC SEC/TAxID# <br /> Owner Home Address U � { DRIVER'S LICENSE# <br /> Gi <br /> City STATE ZIP <br /> Owner Mailing Address <br /> S1 <br /> Mailing Address City State Zlp <br /> TURF ru;nwmFRCNTD <br /> CORPORATION❑ INDIVIDUAL❑ PARTNERSHIP❑ FED AGENCY❑ OTHERTK <br /> FACILITY FILE <br /> FACILITY ID# CROSS REF ID# ��OUNTID# INV# <br /> OMPLETE THE FOLLOWI G BUSINESS I FACILITY SIEE INFORK4770N.- <br /> Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YEs ❑ No 9 <br /> Is this an ExisIING Business LOCATION but a NEW TYPE of regulated Business? YES ❑ No ER <br /> BUSINESS/FACILITY/SITE NAME / <br /> SITE ADDRESS SUITE# BUSINESS PHONE <br /> CITY I I CSTATE ZIP'3 <br /> BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEYS KEY2 <br /> Mailing Address ifDTFFERENTfiom FadlifyAddress Attention:or Care Of(optional) <br /> Mailing Address City STATE ZIP <br /> SIC CODE <br /> AP # COMMENT: <br /> THIRD PARTY BILLING INFO: Completeif Billing Party is different from Property Owner or Facility Operator identified above. <br /> BUSINESS NAME ,y AftV of On:o/Care Of (oplional) <br /> .� <br /> Mailing Address PHONE In 5 <br /> CITY (('' ` (-.4ATE �ZIP <br /> Ate.- 11urennoccc for fees and charges OWNER FACILITY/BUSINESS THIRD PARTY BILLING <br /> Rn 1 LNG aNn f'ovtPt.rANr'P ACKNOWI.rnGMFNT: 1,the undersigned Appficant,certify,that I am the(honer,Operamr,or Authorized Agent of this Business,and 1 acknowledge that all PERMIT FEES, <br /> PENALTTEB,ENFORCF.M 'HARGES and/or HOURLYCHARGES associated with this operation will be billed tome at the address identified above as the A nunc� TAnnRecc 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 JOAQUtN COU.N Y 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 DEPARTMA)T as soon as it is available and at the same time it is <br /> provided to me or my representative. PLEASE PRINT <br /> APPLICANT NAME , � SIGNATURE t , ' <br /> TITLE ;• DRIVER'S LICENS <br /> i �O - IJ' (PHOTOCOPY REOUIR ) <br /> Approved By Date Aaounting Office Processing Complete))By Date <br /> 29-02-002 .April 25,2003 <br />