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San Joaqui*unty Environmental Health Dep*ent <br /> GREEN FORM <br /> DATE 1 3 'O MASTER FILE RECORD INFORMATION "MFR" <br /> SH a nFn Aorec FOR FHA I reFONLX OWNERID# CA SE# UNIT IV <br /> �tDO�D � 5 S � <br /> OWNER FILE <br /> COMPLETE TNEFOLLOWINGPROPERTY OWNER INFORMATION; Off"IF OWNE/RCURRENTLYONFILIF tvIrN EHD <br /> PROPERTY OWNER NAMEC� �,O PHONE <br /> First MI J Last c�G <br /> BUSINESS NAME SOC SEc/TAX ID At <br /> Owner Home Address DRIVER'S LICENSE# <br /> city STATE ZIP <br /> Owner Mailing Address / oQ ©os 6f-0 . <br /> Mailing Address City C �((��,C © , / V�+ state <br /> �<:j7 A Zip <br /> TVVF OFIIWNGGGNrG J �V <br /> CORPORATION❑ INDMDU PARTNERSHIP❑ FED AGENCY❑ OMER❑ <br /> FACILITY FILE <br /> EFACILITY ID# CROss REF ID# ACCOUNT ID# Rabb 3 316 INV# <br /> b 1869'1 <br /> MP Wf FOLLOWrNGMA <br /> Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ NO ❑ <br /> IS this an EIaSTING Business LOCATION but a NEW TYPE Of regulated Business? YES ❑ NO ❑ <br /> B zsiNEss/FAcu.m/SITE NAME Y•� <br /> SITE ADDRESS � SUI�TFE//#-int, BUSINESS P(HOX+E/�. <br /> CM e--- STA L ZIP <br /> BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEYI KO"Z <br /> Mailing Address WDIFFERENTfrons FaciiityActoty" Attention:or Care Of(ophonail <br /> Mailing Address City STATE ZIP <br /> SIC CODE APN# COMMENT: <br /> THIRD PARTY BILLING INFO. Complete if Billing Party is different from Property Owner or Facility Operator identified above. <br /> BUSINESS NAME i / Attention:orCare Of (optional) <br /> �of7a�0� *ar'yh T ✓lol �5 <br /> Mailing Address / 9'$' t`(-4 I/ ,"Jest PHONE <br /> Cm C t o C��O � STATE^� ZIP_ <br /> IP <br /> J <br /> Accau neonate for fees and charges OWNER FACILITY/BUSINESS THIRD PARTY BILLING <br /> No I ING ANDCOMPLIANCE IANCE ACRNOWT vnr.MENT; I,the undersigned Applicant,certify that I am the Owner,Operator,or Authorized Agent of this Business,and I acknowledge that all PERMITFEes, <br /> Pe ..It s,ENMO z:mEw CRSRGE and/or ffom YCicuua S associated with this operation will be billed tome at the address identified above as the AX0tzyTADD%ESS for this site. I 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,opermtoG 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 DEPART M' as soon as it is available and at the same time it is <br /> provided to me Dr my representative. <br /> PLE'� TINT SIGNATURE <br /> APPLICANT NAME 7, -50✓/ C/ <br /> TITLE nt/r��`+ n C•fQ DRIVER'S CENSE# <br /> "((,� ( (PHOTOCOP�REQUI. y 5 /n7 Approved BY (z�/�— Date "Z--v (i Accounting Office Processing Completed BY (� I Dale \'Z.1 5 I n 7 <br /> 29-02-002 Aprd 25,2003 11 <br />