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San Toaquin County Environmental Health tpartment <br /> GREEN FORM <br /> DATE MASTER FILE RECORD INFORMATION "MFR" <br /> 4111�o y UNIT IV <br /> OWNER FILE <br /> COMPLf7E7NEFOLLOKTNCPROPERTY OWNER INFORMA770N., CME«rF OWNER CUR$WvnIrOoe w rr EHD <br /> PROPERTY OWNER NAME 1`1101,1E <br /> Fiat MI Last <br /> B16Qh.5SNA3IE r--,e-0N('4 <br /> ^ SOCSEC/TNID# <br /> Owner Home Address 41&/v I,I,��l//y—(�� DuvER`s LueroE# <br /> City O-N V�/ f STATE ZID Z 3 <br /> �r�/�/vV 7JJ <br /> Owner Mailing Address <br /> Mailing Address City State Zip <br /> rPE OE CRIENER<tnP <br /> CORPORATION❑ IRDMDUAL FED AGENCY❑ OnIER❑ <br /> FACILITY FILE <br /> ,FAUL ID 9 /C�l`l'� CRoss REFID# AC[oo 10# p i .INV# q R�^D <br /> OMP 7NEF LL l M T! N' t \ 1 f YOL <br /> Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ No <br /> Is this an EXSSRNG Business LOCATION but d NEw TYPE Of regulated BusinP55? YES ❑ No <br /> Bts51NESs/FACIlm/Siff NAME <br /> SIZE ADDRESS /YI i/� /y�y rl� 'A SURE# BUSSU ESS PHONE <br /> CRY //I' (E�!- G✓/ v V L� STATE C%/ 7L <br /> Mailing Address ifDIFFEREN7from FadfitfAddr Attention:or Cam Of(ro�todiona/J <br /> Mailing Address City STATE 21P <br /> THIRD PARTY BILLING INFO; Complete if Billing Party isdifferent/horn Property Owner or Facility Operator identified above. <br /> BUSW65 E y-- ������ /AL, <br /> A�Attention:orCare Of ( q!a/) <br /> L/� rlicl. <br /> Mailing Address A-47 Z;,Mf <br /> PHME/ A �—+ //� <br /> 6 <br /> CRY 5700 G , / STATE L! q—. Dss <br /> ACCOMATA^^^ "for fees and charges OWNER FACILITY/BUSINESS � <br /> THIRD PARTY BILLING <br /> 1,the undersigned Applicant,certify that I am the Owner,Operator,or Authorized Agent of this Business,and I acknowledge that all PERAftTFEes, <br /> PENT Ho S,ENEORcEM CNARGFS and/or ROURLYCWIaGes associated with this Operation will be billed tome at the address identified above as the A=n ADDRENV for this she. I also Certify that <br /> all information provided on this applicadan is true and correct;and that all regulated activitim will be performed in accordance with all applicable SAN JOAQUIN CO RMV Ordinance Codes and/or <br /> Standards and STATE and/or FEDEML Laws and Regulations. As the undersigned owner,operator,or agent of the property located at the above facility/site address,l hereby authorize the release of <br /> any and all results and environmental assessment information to SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTD E as soon i n aunt bk and al the same time it is <br /> provided to me or my repr ktiva . <br /> APPLICANTNAM/E� /1///�� /dn�X p� pR SIGNATURE <br /> TITLE / / DRIVER'S RLICENSE <br /> IMfDtED <br /> Apposed By Daft A®untitg Olfire Proreavng Compered By Daft <br /> 29-02-002 April 25,2003 <br />