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r <br /> r O t�J 6 to ,s GREEN FORM <br /> DATE s cr �r '�', MASTER FILE RECORD INFORMATION "MFR" <br /> ~~ UNIT IV <br /> OWNER FILE <br /> rNEAMLORZAKPROOPIERTY OWNER ZNFORNATZOft. LNECK JF O R GtAwtt:TvrzYONFjUWnNEHD El <br /> PWOPB TY OWNIM <br /> NAME /2-"—SS 6 C� 101-AAIOIA�l PHONe u VIEDD <br /> _ Flrst Afl list APR <br /> f1�t9 <br /> Is "Am DHA PIA ) <br /> ���Viv`ts�N; <br /> HLA I 4W <br /> DwnerDrina— <br /> Da m's Ism ICES <br /> Cky STATE ZIP <br /> Owoar Mary#A&rss <br /> Mni ft"&M"Cky scsbe ZIP <br /> r4saerranrw❑ TrrnMfa lal ❑ Oaoraamwro❑ /hn ifLWY❑ t17MFo lJ <br /> U� 10 2,R 362 <br /> IS this a New Buskless LocanoN not Previously regulated M the ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ No ❑ <br /> IS tttls an Eias vw iuskmm LocATION but a New TYm of roynlaeed Business? YES ❑ No ❑ <br /> /FAaLrrY/SITE NAME <br /> SrIE ADORM SULTS# BLWNESS PHONE <br /> Crry ATE m 'F.f x-03 <br /> Address MDDMRL9VTL m Pisa pAdldnw Atbwrdon:or Care Of(opdvrreJ) <br /> KBMV Addnm City STATE ZIP <br /> Rte/OMt1 Y Wili4jm p o: CoflWkw it oiiiing Party is 017re.Tnr from Property Owner or Facia <br /> RY Operator idendfieid above <br /> D1rsn1�N� AtbmTtion:orCere Of (opdoewl) <br /> LLD u w�v N <br /> Addressd151 '�SALVID 41,9tgNe <br /> :rT` O A^ STATE ZZP <br /> for.m and Manges OWNER FACILITY/RUSINESS THIRD PARTY RAILING <br /> ILLING AND COMPI,.Nry Ar'KNnMLI FIDGMENT: 1,the undersigDed Applicant,certify that I am the Owner,Opermor,or AuAor/1ed Agent off d-d `wkd;that all PER.tftT FELS, <br /> NALTIES,ENFORCE,NENT CHARGES and/or HOMMYCHARGES associated with"operation will be billed to me at the address Identified above as the dL02rNTdQQgEss for this site. I also certify that alt <br /> kvmdoa provided on trls application Is true and correct;and that all regulated activities will be performed In accordance with all applicable SAN JOAQviN COUNTY Ordinance Codes an/or <br /> =lards sad STATE and/or FLDrJtAL 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 /> V and ail results and environmental assessment information to SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It is available and at the same time It is <br /> rvided to me or my representative. <br /> PLEASE PRINT <br /> 1PPLICANT NAME R 0 of 99(L n h4/A J. / SIGNATU s <br /> WILE �W N��2 �/l�/ fnaToaoDRIVER'S LICENSE a �G/�Q� 0(arr Inptrnt�) <br /> TMINI IL11 I IAL <br /> S1N� �� <br />