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San Joaquin County Environmental Health Department <br /> DAA 1ZO 1O b GREEN FORM <br /> 3 MASTER FILE RECORD INFORMATION TtMFR" <br /> Suenen ALree ena Fun um nev OWNERID# CASE# UNIT IV <br /> OWNER FILE <br /> COMPLETE 7HEFOLLOWING PROPERTY OWNER INFORMATloN; fEcru OWNER CURRENTLYONFILE wnH EHD <br /> PROPERTY OWNER NAME 5� &-d <br /> __4Ate' PHONE <br /> �First Ml Last <br /> BUSINESS NAME ♦ A/Iu $OCSEC/TAX ID# <br /> Owner Home Address /6 O'O 5 r �r'?Tr,f srt DarvER's LICENSE# <br /> city 5 Apc,4 r-e� GA srAn4A zm 9SLo6 <br /> Owner Mailing Address <br /> Mailing Address City State Zip <br /> CORPORATION INDIVIDUAL.❑ PARTNERSHIP El FED AGENCY El OXER❑ <br /> FACILITY FILE <br /> EF <br /> ID# eeosS REF ID# AccouNr ID# INV# <br /> CQMPLETE THEE LL WIN ry <br /> Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? VES ❑ No SP <br /> Is this an EXISTING Business LOCATION but a NEW TYPE of regulated Business? YES ❑ No ®7 <br /> BUSINESS/FAmJrY/SINE NAME 5;#14S <br /> Sm ADDRESS /600 S ♦ ��A �� ' <br /> sum# BUSINESS PH LC R <br /> ^J�EyBr Oc>b <br /> Cm L_G�/ STATE eA ZNv <br /> BOARDOFSUPERVISORDasnucT LOCATION CODE KErI KEYZ <br /> Mailing Address if DIFFERENTfinlrl Fan/itFAddreYs 1 F/A Attention:or Care Of(optional) <br /> Mailing Address City �f <br /> SPATE Zn <br /> SIC CODE APN# COMMENT: <br /> THIRD PARTY BILLING INFO; Completeif Billing Party is different from Property Owner or Facility Operator identified above. <br /> BUSINESS NAME /' <br /> C ./ Attention:orCare Of (optltlarw/J r� ��K� <br /> Gw CKL. <br /> Mailing Address 106 70/ ♦. 1 L iv� �� /1 Gr/A, S,f C ivo PHONE(1y�6 0 36.32 08 <br /> Cm ,Q4«G4t <br /> C,0 WA0 dar �� SPATE e04 Zn' /pcSCrs 70 <br /> ACCRDNEADORESA'for fees and charges OWNER FACILITY/BUSINESS THIRD PARTY BILLING <br /> BILLING AND COMPI JANLE ACKNOWI Tn 1,the undersigned Applicant,certify that 1 am the Owner,(Jpemtor,or Authorized Agent of this Business,and I acknowledge that all PERMIT FEES, <br /> PENALTIES,C'NFORCEA)£NTCHARGES and/or HOURLYCHAROEystsoelated with this operation will be billed to meat BIQ addre"identified above a5 Bre ACCOIMTAI)nRF of far this site. I aim cerdfy that <br /> all information provided on this application is hue and correct;and that all regulated activities will he 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 ofthe property located at the above facility/site address,I hereby authorize the release of <br /> any and all remits and a mental assessment informatioD to SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the some time it is <br /> provided to me or my repre ,rive. <br /> APPLICANT NAME PLEASE PRINT <br /> SIGNATURE <br /> TITLE <br /> DRIVER'S LICENSE# <br /> (PHOTOWPY REOUIRED) <br /> Approved BY Dale ACCO....Office%oc mj Completed BY Date <br /> 29-02-002 April 25,2003 <br />