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San Joaquin Countylic Health Services Environme� Health Division <br /> sp GREEN FORM <br /> DATE MASTER FILE RECORD INFORMATION "MFR" <br /> SHADED AREAS FOR EHD USE ONLY OWNER ID# UNIT IV <br /> OWNER FILE <br /> COMPLETETHEFOLLOW/NG PROPERTY OWNER INFORMATION.- CHECKIFOWNER CURRENTLYON FILE WITHEHD � <br /> PROPERTY PHONE <br /> OWNER NAME <br /> Firxf MI leaf <br /> BUSINESS NAME /+ L O c—o <br /> ` SOC SEC/TAX ID# <br /> Owner Home Addresst� O� �O 1 Uj a _( 5� <br /> I DRIVER'S LICENSE# <br /> City { LN/Y\ e-�.s1 T CJ STAT rf — ZIP <br /> Owner Mailing Address (fir t / aJ ✓ <br /> Mailing Address City State Zip <br /> CORPORATION INDIVIDUAL PARTNERSHIP FED AGENCY F1OTHER <br /> FACILITY FILE <br /> FACILITY ID# CROSS REF ID# I ACCOUNT ID# INV# <br /> COMPLETE THEFOLLOW/NG BUSINESS/ FACILITY/ SITE INFORMATION.- <br /> Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DIVISION? YES ❑ NO ❑ <br /> Is this an EXISTING Business LOCATION but a NEW TYPE Of regulated Business? YES ❑ NO ❑ <br /> BUSINESS/FACILITY/SITE NAME /^ <br /> . 1� <br /> l <br /> (A <br /> SITE ADDRESS � 5 0 �0 SUITE# BUSINESS PHONE <br /> CITY QCO` STATE ZIP / S 33 <br /> BOARD OF SUPERVISOR I LOCATION ( I KEY1 I I I(EY2 <br /> Mailing Address if DIFFERENT from Facility Address Attention: or Care Of(option/) <br /> Mailing Address City STATE ZIP <br /> SICCODE = APN# ,COMMENT; <br /> THIRD PARTY BILLING INFO: Comp/eteif Billing Party is differentfrom Property Owner orFacility Operator identifiedabove. <br /> BUSINESS NAME Attention: or Care Of (optional) <br /> Mailing Address PHONE <br /> CITY STATE ZIP <br /> ACCOUNTAoaaess for fees and charges OWNER FACILITY/BUSINESS THIRD PARTY BILLING <br /> BILLING AND COMPLIANCE ACKNOWLEDGMENT: I,the undersigned Applicant,certify that I am the Owner,Operator,or AuthodzedAgent of this Business,and I acknowledge that all <br /> PERH?FEES,PENALTIES,ENFORCEAfENT CHARGES and/or HOURLY CHARGES associated with this operation will be billed to me at the address identified above as the ACCOUNTAVDRES;S <br /> for this site. I also certify that all information provided on this application is true and correct;and that all regulated activities will be performed in accordance with all applicable SAN <br /> JOAQUIN COUNTY Ordinance Codes and/or Standards and STATE and/or FEDERAL Laws and Regulations. As the undersigned owner,operator,or agent of the property located at the <br /> above facility/site address, 1 hereby authorize the release of any and all results and environmental assessment information to SAN JOAQUIN COUNTY ENVIRONMENTAL <br /> HEALTH DIVISION as soon as it is available and at the same time it is provided to me or my representative. <br /> PLEASE PRINT <br /> APPLICANT NAME SIGNATURE <br /> TITLE DRIVER'S LICENSE# <br /> _(PHOTOCOPY REQUIRED) <br /> Approved By Date Accounting Office Processing Completed By Date <br />