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San Joplin County Environmental Health Dortment <br /> DATE ( 6,/,12°`-1:10. MASTER FILE RECORD INFORMATION "MFR" GREEN FORM <br /> SHADEDAREASFOREHDUBEONLY OWNER ID# CA SE# UNIT IV <br /> OWNER FILE <br /> COMPLETE THEFOLLOW/NG PROPERTY OWNER/NFORMAT(oN.' CHEcr/F OWNER CuRRENnvoNnizidiny EHO <br /> PROPERTY OWNER NAME PHONE y1s- 000 <br /> First MI Lest <br /> BUSINE9s NAME y ll SOC SEC/TAXID# <br /> Ownar Htune Address �/l 'L-�cl�� ��} !\ �✓'Cv✓\C,l S�.'. 1 (CS- DRIVER's LICENSE# <br /> City /// 7 STATE zip <br /> Owner Mailing Address <br /> Mailing Address City State zip <br /> CORPORATION`o INDIVIDUAL❑ PARTNERSHIP❑ FED AGENCY El OTHER El <br /> FACILITY FILE <br /> FACILITY ID# CROSS REF ID# ACCOUNT ID# INV# <br /> COMPLETE THEFOLLOW/NG BUSINESS I FACILITY I SITE/NFORMAT(ow <br /> Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPT.? YES ❑ No 10 <br /> Is this an EXISTING Business LOCATION but a NEW TYPE of regulated Business? L� YES ElNo H <br /> BUSINESs/FACIUW/SITE NAME Gr:1 A:e V,�Ilsn C�W6-('�-F-br S^�0,-\t c,^ ,,yL ) <br /> SITEADORESS ..� SUITE# BUSINESS PHONE'J�)�t` <br /> CITY I�A(,I e C cv STATE(./� zIPclK TS- <br /> BOARD OF SUPERVISOR DISTRICT LmAroNCODE KErl TK-2 <br /> Mailing Address HO/FFERENTIrom Facl/ltyAddiese II ANengon:ar Care Of(opt/onall) <br /> U h..UW C ✓l <br /> Mailing Address City Sc,..n �u„�v ,� STATE(' ZIP (J �u'S <br /> SIC CODE APN# COMMENT. .1 <br /> THIRD PARTY BILLING INFO: Complete ifBilling Party is different from Property Owner orFacility Operator identified above. <br /> BUSINESS NAME Attention:orCare Of(opLme/J <br /> s <br /> 1 on<-, r <br /> McRhlg Addreoom LCJ {-(JC%�CC Vv'LI\ PHONE ( �G�) . ./(1�— , l ` I <br /> CITY`.'\l��' j STATEC 7JP cb_t <br /> AErolwrA,_ays for fees and charges OWNER FACILITY/BUSINESS THIRD PARTY BILLING <br /> BILLING AND COMPLIANCE ACKNOWLEDGNIENT: 1,the undaasigned AFplicant,certify that 1 em Ilte tAvner,Operat,,rs ar Al/t/I..rired Agent of this Business,and 1 acknowledge that all PERAsn'FEEs', <br /> PENALn£.5',ENFOAC'EAMN)'C11ARl1E5'And/m'Rr1URLYCHARGEr nsseeiated With this Operation will be billed to mass the address identified above as the ACY'OUM'ADDRE5:5'for this site. I also certify Ilial <br /> all info,notion provided on this application is true and correct;and Ilial all regulated netivilice will be perforated in accordance with all Applicable SAN JOAQUIN COUNTY Ordinance Codes and/or <br /> Standards and STATE and/or FEDERALLaws and Regulations. As the undersigned owner,operemq or agent of the properly located at the above foci /site nddresa,I he malawfi,the release of <br /> any and all results and environmental assessment information to SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DF'PA/ YM1iFhNT u n it is nvp'a And at the same time it is <br /> provided to me or my I epresenlative. (///' A//� / <br /> EAg !( `/ r <br /> APPLICANT NAME Vc .So nS [G r��. //`'IPL(_ 1.eiLa.Ll SC�tti.�A�tL�;'I SIGNATURE i r (_, �(%'✓ - <br /> TITLE .{. y DRIVER'S LICENSE# <br /> � o\\ V S- L( P_/L \ 1 f) \ (PHOTOCOPY REQUIRED) -- <br /> Approved By Date Aecoonting ORlee Processing Completed By Cr Det.9 \ 9,) 0 8 <br /> 29-02 10/12/07 MASTER FILE RECORD-GREEN <br />