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GREEN FORM <br /> °ate -�0 M,TER FILE RECORD INFORMATIO, MFR'S <br /> f1�D�Q ARDS/OR HD�� On T i� <br /> I <br /> OWNER FILE IJJQ <br /> COMPLE7L me t-piLOW)NGPROPERTY OWNER INFORmAT)ON' CMEcIlrF_.C�N(slf?R Cu e�YroRrFiLEtyrTrrEH4� <br /> PROPERTY I PHONPERM1 i vCHV;��'v <br /> I <br /> OWNER II <br /> BUSINESS NAME i SOC SEC/TAX ID tt <br /> I S <br /> Owner Homo Address 1161417AU ,epi DRwER's LtcENsE tl <br /> City i STATE ZIP <br /> U.nor Maili•.g AAQtoa i <br /> Mailing Address Cit. State Zip <br /> CORPORATION I INDIVIDUAL 0 PARTNERSHIP 0 FED AGENCY 0 OTHER <br /> FACIUTY FILE <br /> 3OMPLE7rMEF�LtoiI BUSINESS/FACILITY I SITE /NFoi?mATioly: <br /> is this a NEw Busine S LOCATION not previously regulated by the ENVIRONMENTAL HEALTH Division 7 YES C NO 0 <br /> :;this an ExtsnNG Busineaa LocnnooN but a II TYPE of regulated Business 7 YES ❑ NO C <br /> "i USINE9alFAC1UTYISI i E NAM/,_ 1. y r D /- <br /> SITE ADDRESS i �fir~ SUITEBUSINESS PHONE <br /> CITY I ^ .�� STATE 21P <br /> tbA ? 'MMI <br /> Mailing Address lfdIIFFERENTfrom FacdifyAddress Attention: or Care Of(optional) <br /> Mailing Address Ci STATE ZIP <br /> S <br /> "HIRD PAItTir BILLING INFO: Complete if Billing Party is different from Property Owner orFacility Operator Identified above. <br /> euslNEss NAME IAttenti :or Care Of (optional) ° <br /> 1.ae Ery Pe/'ii� �'I c , r�ru <br /> Moiling Address { T J�� n 1 v� PNONE <br /> PITY I ✓�jGJ�Du/ i[, �/ STaTE [�v ZIP Ad <br /> .4qqoy&XA2P9.,I for fern and charges OWNER FACILITY/BUSINESS THIRD PARTY BILLING <br /> :fit LING AND COMPLIANC.ALJC.WOWLFDC:Mr,:r•I: I,the undersigned Applicant,certify that I am the Owner,Operator,or,AuMarized.ggety of this Business,and I acknowledge that all <br /> •�;rcurrFEBs,PHN.Airtas;ENFOlrcF_4IfFvrCIldRGeS■nd/orHaURLVCMARGFS associated with this operation will be billed to me at the nddreva identirnd above as the.1CWUNrMnRP[S <br /> •r this site. I alsocerci that sU information provided on this application is true and correct;and that all regulated activities will be performed in accordance with all applicable SsN <br /> J+QUIN COUNTY Ordinance Codes and/or Standards and STATE and/or Ftn¢rur.Laws And Reguladonn. ,L.the undersigned owner,operator,or 3icnt of the property Ionated at the <br /> ;. a facility/site address. I hereby authorize the releme of any and nil resulut and environmental asse"ment information to NAM JOAQUIN COUNTY ENVIRONNTE,4 'AL <br /> FA LTH DIVISIONS as 40on as it Is available and at the same time it is provided to me or my representative r <br /> PI-a%I-PRINT <br /> APPLICANT NAME SIGNATU <br /> TITLE <br /> 2/�/� DRIVER'S LICENSE 9 <br />