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0 <br />0 <br />San Joaquin County Environmental Health Department <br />DATE 12-3 13 GREEN FORM <br />MASTER FILE RECORD INFORMATION "MFR" <br />SHADED YIFAf FOR END USE ONLY OWNER ]DO CASE# UNIT IV <br />OWNER FILE <br />INrsla"AT/AA/• CHEDK(F OWNER CURR£NrtraNnLEW?N EHD n <br />PROPERTTOWNERNAME <br />!amid <br />C <br />Sarynsn <br />PHONE 925680-0777 <br />KEY2 <br />Fire( <br />MI <br />Last <br />BUSINESS NAME Shea Mountain House LLC <br />TMIDN <br />Owner Home address 51 Belle Avenue <br />DRIVER'S LICENSE 0 <br />city San Anselmo <br />STATE CA <br />7JP94960 <br />owner Malltng Addrooa 2630 SHEA CENTER DRIVE <br />Malltng Address City LIVERMORE <br />Smote CA <br />ztp 94551 <br />CORPOMTION❑ INDIVIDUAL❑ PARTNERSHIP [I FED AGENCY❑ LLC® <br />FACILITYFILE j:,h(,IVVq (FHb <br />FACILITY ID # CROSS REF ID # AccouNT ID # INV# <br />COMPLETETHEFOLLGWING BUSINESS I FACILITY I SITE /NFORMA77oN.' <br />I_sthis _a_New Business LOCATION notpreviously regulated by the ENVIRONMENTAL HEALTH YES ❑ NO ❑ <br />IS this an EXISTING Business LOCATION but a NEW TYPE Of regulated Business? YES ❑ NO ❑ <br />BUSINEssIFACILRY/SRENa se SHEA MOUNTAIN HOUSE LLC <br />SREADOness 2630 SHEA CENTER DRIVE SUITE# BUSINESS PHONE 925.246.3800 <br />Cm LIVERMORE STATE CA 7JP94551 <br />BOARD OF SUPERVISOR DISTRICT <br />©J <br />LOCATION CODE <br />Qq� <br />Kul <br />KEY2 <br />Malltng Address ffOIFFERERrfivm FeciiifyAddrass Attention: or Care Of(npdonG0 DAVE SARGENT <br />Mailing Address City IfjI <br />SIC CODE <br />THIRD PARTY BILLING INFO:` <br />BUSINESS NAME <br />Mailing Address <br />CITY <br />AFNIt 242-640 -13 II COMMENT: <br />Completed Billing Party is different from Property <br />STATE ZIP <br />ar Cr Facility Operator identified above. <br />Attention: orCare Of (opNional) <br />STATE ZIP <br />AceaVATAQpgE@9 for fees and Charges OWNER FACIUNIBUSINESS THIRD PARTY BILLING I <br />DILLING AND COMPLIANCE Atl:NOTVLEoo>IgbT. I, the undersigned Applicant, certify that I an the Myna, Operator, mrdrudorized:igenf of this Business, and I acknowledge that all PERMTf FE( , <br />PFNALnF$ENFOAC£al£ATCfL1RGEs and/or R0V&I'CIL1RGEY oamdoted with this operotion will be billed tome at [headdress identified above as thele[euATefnnRFce for this site, I also certify that all <br />tnformaflan Provided On this vppliesthm Is true and correct; and that oil regulated activities hill be performed in accordance nits all applicable SAN JOAQUIN COuNnnr Ordinance Coda and/or <br />Slandards and SLUE and/ar FEDEML L fans and Reguladuns. els the undersigned olynea operator, or agent of the properly located at t ah�"* <br />e rm ilit)•/stl�s(�Ili revs, I hereby nulhodre the release of <br />any and an results and environmental I,m ,ment information to SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEP RTD va soma ve' 's available and at the same time it Is <br />provided to me or my representative <br />PLEASE PRINT SIGNATURE <br />APPLICANT NAME OoWd ssaonL � <br />TITLE AuthoHmd/ <br />Agent <br />29-002 <br />