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San Joaquin County Environmental Health Department <br /> GREEN FORM <br /> DATE MASTER FILE RECORD INFORMATION "'MFR'y <br /> Iqf4AnFn ARFA4 FQR FHn lisp nNI V OWNER ID# CASE# UNIT IV <br /> OWNER FILE <br /> Co,wPLETE THE Foi i o w-rNG P RO P E RTY OWNER INFORMATION; CHEcKiF OWNER CtntReivri YoN"1,1 wiTiLl EHD El <br /> PROPERTY OWNER NAME I ��0 --aln 'i<.I e- PHONE IC) - 9 <br /> First M/ Last <br /> Busmt ID# <br /> -Ty, 4, \ tip It- <br /> Owner Home Address d DRIVER'S LICENSE At <br /> e,,C4,-( <br /> citySTATE <br /> \-6(CA ZIP 17e-j, <br /> Owner Mailing Address <br /> AddressMailing City y a [-state 00- ZIP <br /> TYPF rip in <br /> CORPORATION❑ INDIVIDUAL❑ PARTNERSHIP❑ FED AGENCY❑ OTHER <br /> ILEFAFACILITY-FILE _ <br /> FAcnrrY <br /> ctu'ry ID# CROSS REP ID# ACCOUNT ID# INV# <br /> CAgMPLETE 7NE FOLLOWING BUSINESS JUACII-InLi SITE AM"Af 7TON: <br /> Is this a NEW Business LOCATION not preViouslV regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ No ❑ <br /> Is this an ExIsrING Business LOCATION but a NEW TYPE of regulated Business? YES El No El <br /> BUSINESS/FACILITY/SITE NAME <br /> SITE ADDRESS9VA, SUITE# BUSINESS PHONE 0 so(A2 <br /> CITY STATA ZIP <br /> I ya Op <br /> OA-. SuPERvisoR DISTRICT LOCATION KEY1 <br /> Mailing Address ffDrFFERENrfrom FadlityAddress Attention:or Care Of(optional) <br /> Mailing Address City STATE ZIP <br /> SIC Comm <br /> THIRD PARTY BILLING INFO: Completed Billing Party Is different from Property Owner or Facility Operator identilIed above. <br /> BusmEss NAME Attention:orCare Of (optional) <br /> Adllorl(7,ra nua4--AZ21, --- <br /> Mailing Address 2PHONE 7 (VOq) <br /> CITY b <br /> -IkIZA-) 'T <br /> P Z, <br /> A=vjvT-.APPwE-,w for fees and charges OWNER FACILITYIBUSINESS THIRD PARTY BILLING <br /> 13 LUNG AND r M111 IAN(-E AcKNOwL undersized Applicant,certify that I am the Owner,Operator,orAuthorizedAgent of this Business,and I acknowledge that an PERMIT FEES, <br /> atmyrfr: 1,the undersig <br /> PENALiiEs,E,vF�ORcaw,A,rCHA,RGEsa HOUNLYCHARGE9 associated with this operation will be billed to me at the address identified above as theAMOUNTA721) 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 JOAQUIN 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 DEPA"NT as soor"s it is available and at�the same�tiiniit is <br /> provided to me or my representative. <br /> PLEASE PRINT <br /> APPLICANT NAME SIGNATURE <br /> Z, <br /> TITLE DRIVER'S LICENSE* <br /> (PHOTOCOPY REWIRED) <br /> -—----------------------- <br /> App-ved By Date Accounting Office Processing Completed By j Date <br /> 29-02-002 April 25,2003 < <br /> ,eee,477,401� C-M,WL 01-7 l07 <br />