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' <br /> San Joaquin County Environmental Health DepartmentORIGINAL <br /> GREEN FORM <br /> DATE - MASTER FILE RECORD INFORMATION "MFR" <br /> SNAnFn ARFec FnR F14n IICF nany (?Zn <br /> �l],�!/Z / / UNIT IV <br /> �/ /OWNER FILE <br /> COMPLETETMEFOLLOWING PROPERTY OWNER INFORMATION; CHECKIF OWNER CVRREN7zr0NFILEwrrH EHD <br /> PROPERTY OWNER NAME �/ f�,TI / — S' PHONE J — �7� -- 70/11' <br /> First MI Last <br /> BUSINESS NAME -I f�//��' 1 SOC SEC J TAX ID# <br /> Owner Home Address �Oj� � //G'�— �y DRIVER'S LICENSE# <br /> city "Y 1 STATqC�_ ;DP J''2 <br /> Owner Mailing Address <br /> Mailing Address City State Zip <br /> 7YDF(IF DWNFRrM <br /> CORPORA INDIVIDUAL❑ PARTNERSHIP❑ FED AGENCY❑ OTHER❑ <br /> I <br /> �-+' FACILITY FILE <br /> FACILITY ID# J � .Y CROSS REFID# ACCOUNT ID# I� /� I INV# <br /> COMP TME F LL D BUSINESS I FACILM SrrE NMATT , C l V 1p <br /> Is this a NEw Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ NYd <br /> Is this an EXISTING Business LOCATION but a NEW TYPE of regulated Business? YEs No ❑ <br /> BU57NE55/FACIIITY/SITE NAME fZ L <br /> SITE ADDRESS97 <br /> W tli; SUITE# BUSINESS PHONI!551Qe'� <br /> CITY <br /> C / <br /> C �ti l c k ► V ZIP �5�j%�j 3 <br /> Mailing Address WDIFFERENTfram Faci/ityAddretis Atte tion: Care Of(optional) <br /> Mailing Address City STATE ZIP <br /> E:� <br /> THIRD PARTY BILLING INFO: Completed Billing Party is different from Property Owner or Facility Operator identified above. <br /> BuslNEss NAMEAttention:or Care Of (optional) <br /> vo� )! ':�z— - 15Z)1'rz al,lb' s <br /> Mailing Address S PHONE <br /> Cm / -_ `_/t^ STATEC,>L ZIP 95 LTL <br /> A14CQU W.A�^C^.9fas for fees and charges <br /> OWNER FACILITY/BUSIN THIRD PARTY BILLING <br /> H11.[.1NC 4NI1 COMPLIA NfR A('KNOW E"GNIFNT: I,the undersigned Applicant,certify that I am the Owner,Operato,or I-,h.r,-djg_--fTb.s.Business,and I acknowledge that all PERMITFEES, <br /> PENAI.77ES,ENFORCEMENTCHARGES and/or HOURLYCHARGES associated with this operation will be billed to me at the ve as the ACCOILATAnnRecc 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 JOAQLTN 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,I hereby authorize the release of <br /> any and all results and environmental assessment information to SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon <br /> a�s it is available an at the same time it is <br /> provided to me or my represen t' <br /> APPLICANT NAME PLEASE PRIIrT SIGNATURE t <br /> TINE c v cr� DRIVER'S LICENSE# <br /> (4e/& U (PHOTOCOPY REQUIRED) <br /> APp�; By Date Accounting Office Processing Completed By Date <br /> 29-02-002 April 25,2003 <br />