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San Joaquin County Environmental Health Department"` <br /> GREEN FORM <br /> DATE <br /> � MASTER FILE RECORD INFORMATION "MFR" <br /> c eF•�cnnFMn ..Fnw. OWNER IDSb�.,,�.Oa lisg� CASE= UNIT IV <br /> OWNER FILE <br /> CoMPLETETHEFOLL.OWINGPROPERTY OWNER INFORMATION: CHECKIF OWNER CuRaENrLYONFiLEWr7NEHD <br /> PROPERTY PHONE <br /> OWNER NAME <br /> Fist Mt last <br /> Bus uEss NAME / 2� — Soc SEC I TAX ID i <br /> Owner Home Address 3s-6o Armee-f '�..'✓(—N-- DRWER•sLICENSE# <br /> City An n,'�"N� STATE / /1 ZIP <br /> Owner ranine Addnns '4 ! v A <br /> Mailing Address City State Zip <br /> rnRPnRATrn%1 1 INnnnnI tai 1 1 PARTMFRCNIP n Fon Arotary I I nTHFR 11 <br /> FACILITY ID i �"_ �n,�+ j<..1 CROSS REF ID* ACCO{(NT ID i A"6-,Lt ( I Iww 01j 0•L�-�S %�_ 1 <br /> COMPLETE THEFOLLOWING BUSINESS CI 1 / IT INFORMATION: <br /> Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ No <br /> Is Mis an E)uSTING Business LOCATION but a NEW TYPE of regulated Business? YES ❑ No <br /> BUSINESSIFACILITY/$ITE NAPE <br /> SITE ADDRESS � SUITE 0 BUSINESS PHONE <br /> A-cr-�-2-rw,2 �o,�-� <br /> CITY � ATE ZIP� � <br /> BOARD OF SUPERVISOR ( C LOCATION CODE , } KEY1 �. KEY2 <br /> Mailing Address/f D/FFERE 0 FT from Facility Addhas Attention:or Care Of(optional) <br /> Mailing Address City STATE ZIP <br /> SIC CODE APN r (`.OrrENT_ <br /> THIRD PARTY BILLING INFO: Complete If Billing Party Is dff7`erentfromProperty Owner orFacility Operator Idendfledabove, <br /> BUSINESS NAME Attention:or Care Of (opt5io»al <br /> D LC)f\tI <br /> Mailing Address O / u n 1 PHONE <br /> (iITYWZ ('!'0 �� � = STATE q ZIP qC /) �' <br /> ACCOIINT ADDRF.44 fnr faax and rharnac OWNER FACILITY/RusiNESS HIRD PARTY KILLING / <br /> Rn.LING AND COMPLIANCE ACKNOA17I.F.O(_MRNT: I,the undersigned Applicant,certify that I am the Owner,Operator,or Authorized Agad of this Business,and I acknowledge that all PERWT FEE <br /> PF.NALTTES,EvFVRCEMF-NT CtIARGFS andtor EOE/RLPCAARGES associated With this operation will be drilled to nue at tale address Identified above as the for this Site. I also certify drat <br /> information provided on oris application is true and correct;and that all regulated activities will be perforated in accordance with all applicable SAN JOAQUIN COUNTY Ordinance Codes and/or Standar <br /> 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 sud wriae the release of any and <br /> results and en iromaren tal assessment information to SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is provided to ne or r <br /> representative. <br /> PLEASE PRINT <br /> APPLICANT NAMEJ)4 C k, -e SIGNAT <br /> TITLE <br /> DRIVER'S LIC N E F j� T/ D U <br /> y Q o <br />