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1110 1 San Juin County Environmental Health Ifartment <br />DATE � s -Q � MASTER FILE RECORD INFORMATION "MFR" <br />SHADED AREAS FOR END USE ON1 Y OWNER ID# a IJ S C' CASE # <br />GREEN FORM <br />UNIT IV <br />OWNER FILE <br />f'nAIDIFTFTNFFnIInWTNr_`DDnDCD,ry A\A/IuCD TATC^0"AT ^— CHECKIF OWNER CURRENT[ YON FILE WITH EHD <br />PROPERTY OWNER NAME <br />/1 p A 7 /'_ <br />J7 F, 1�+ W <br />No <br />No ❑ <br />BUSINESS/FAcuml SITE NAME F i -o J#2�L4L"=J <br />PHONE L _ <br />! 6 V 606 <br />SITE ADDRESS CL <br />VOzo <br />First <br />Ml <br />Cm <br />Last <br />(p L <br />BUSINESS NAME (/,t� <br />C LL \ [ �✓� v%,, �J'ltil <br />L <br />LC7 I`O�'I. i1 <br />1/� <br />SOC SEC/ TAx ID # <br />Owner Home Address ` G y v v G' e l ( <br />`� - /\ <br />/ i�/D l <br />J <br />DRIVER'S LICENSE # <br />`/ <br />City J �C ✓-C,1,f 1n J <br />Owner Mailing Address <br />4 ()U Go <br />Mailing Address City J CCL" Lu O <br />/// /// <br />/ / 95 ,,� <br />V <br />n. i l,. " <br />�/y O 7 <br />, <br />j_J� (y'r< t <br />SATE�l <br />ZIP <br />State <br />Zip Lt J Z Q/O / <br />TVDF np nWNFRCNTD <br />CORPORATION ❑ INDMDUAL ❑ <br />I// � /�WQ_ /MQjI• <br />FED AGENCY 5 OTHER ❑ <br />0 ass .cro <br />AFACILTrYID# OD`p^91� CROSS REF ID# I e kD�6gQ ACCOUNT ID# Inv# <br />d-mwPi FTF TNF FnIIn1A/TNG •C RI ICTIUCCC I CArTI TTT <br />V I CTC TIA/IcneuwrTnu. <br />Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? <br />Is this an EXISTING Business LOCATION but a NEW TYPE of regula usiness? <br />YES ❑ <br />YES V <br />No <br />No ❑ <br />BUSINESS/FAcuml SITE NAME F i -o J#2�L4L"=J <br />SITE ADDRESS CL <br />VOzo <br />SUITE # <br />BUSINESS PHONE <br />Cm <br />STATE <br />ZIP <br />BOARD OF SuPERvrsoR Dtsmcr <br />LOCATION CODE <br />KEY1 <br />KEY2 <br />Mailing Address ifDIFFERENTfrom FacilityAddress Attention: or Care Of (optional) <br />Mailing Address City <br />STATE <br />ZIP <br />SIC CODE <br />COMMENT: <br />THIRD PARTY BILLING INFO: Complete if Billing Party is different from Property Owner or Facility Operator idendfled above. <br />BUSINESS NAME Attention: or Care Of (optional) <br />Mailing Address <br />l90 <br />PHONE <br />STATE ZIP <br />' 1IlYYI//NT A/f/fOLCC for fees and charges �� OWNER' <br />FACILITY/BUSINESS THIRD PARTY BILLING <br />Rn.i ING AND COMPI.tANCE ACKNOWLEDGMENT: I, the undersigned Applicant, certify that 1 am the Owner, Operator, or Authorized Agent of this Business, and I acknowledge that all PERMIT FEES, <br />PENALTIES, ENFORCEMENT CHARGES and/or HOURLY CHARGES associated with this operation will be billed tome at the address identified above as the ACCOUNTADDRfor this site. 1 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 DEPARTMENT as soon as it is available and at the same time it is <br />provided to me or my representative. _.� <br />APPLICANT NAME PLEASE PRINT <br />7c -)k (' g • No 0 C (hay-) SIGNATURE aa6 / /•� _� �„ <br />TITLE A ' DRIVER'S LIC SE # <br />1\ C.C:Ji"U V Q/YY I <br />(PHOTOCOPY R UIRED) <br />Approved By - _- _ Date Accounting (Mice Processing Completed By C� Date �.�' I k l 67 <br />29-02-002 April 25, 2003 <br />