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San Joaquin County Public Health Services Environmentft �l � ► }� <br /> . <br /> /7/=. aO© MAST� '� 200 <br /> ILE RECORD INFORMATION " -OREENFORM <br /> DATE <br /> SG <br /> SHADED AREAS FOR EHD USE ONLY .OWNER ID# CASE# = ' <br /> :All U1211AIlArrrr <br /> PJ � UtomN <br /> IT I V <br /> OWNER FILE <br /> COMPLETE THEFOLLOW/NG PROPERTY OWNER /NFORMA T/ON.- CHECKEWTa❑ t <br /> LL LYON FILE WITH E HD FJ <br /> PROPERTY <br /> PHONE <br /> jOWNER NAME lei) ' _ �- '(J`ff2-, <br /> fast MI last <br /> BUSINESS NAME SOC SEC/TAx ID# <br /> • V i 1,r h �,e q, it C JL et 0;11,0 —Ifi <br /> ?:! , <br /> Ji�' <br /> Owner Home Address �-. _ •7'f0 L':- to,,e j ��' DRIVER'S LICENSE# (� <br /> City >' h Y1 STATE ZIP J Ll <br /> Owner <br /> Owner Mailing Address / "7 V <br /> Mailing Address City S( State , Zip -o <br /> ryN.- <br /> CORPORATION 0 INDIVIDUAL❑ PARTNERSHIP❑ FED AGENCY❑ OTHER❑ <br /> 1 FACILITY FILE <br /> FACILITY ID# O �d �- CROss REF ID# I ACCOUNT ID# <br /> COMPLETE THEFOLLOW/NG BUSINESS/FACILITY/SITE /NFORMAT/ON: <br /> Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DIVISION? YES NO ❑ <br /> Is this an ExiSTING Business LOCATION but a NEW TYPE of regulated Business T YES ❑ No <br /> BUSINESS/FACILITY/SITE NAME <br /> a1-tzlr«r,�,l�,r t=Veil; t i <br /> SITE ADDRESS ,? tQ S.>A fl, US 7 r h [�• SUITE# BUSINESS PHONE <br /> / �> (, <br /> -r�"�"'a•e-•e• �+---e+y�--ter/...�--ai��� f�Tr7•�, �.-x..4.+.i.rr ;b r)`b'sZil�•lr` 'rl L 7Li I) `fi'v U� �� - ,Z <br /> CITYJ �+Tr � <br /> STyATE ZIP <br /> BOARD OF SUPERVISOR ) .. .. I LOCATIONCODEwL ......... <br /> Mailing Address ifD/FFERENTfromm Faci/ityAddress �p Attention:or Care Of(optional) v <br /> J E, lrk- HP�4 e' y , 1 ��. 1J'-rt�.a✓�a�o CSR f��'�,f <br /> Mailing Address City STATE ZIP <br /> SIC CODE APN# COMMENT: <br /> THIRD PARTY BILLING INFO: Complete if Billing Party is differentfrom Property Owner or Facility Operator identified above. <br /> BUSINESS NAME �/f 7 Attention:or Care Of (optional) <br /> Mailing Address PHONE <br /> Z-rLl� <br /> CITY j' STATE ? ZIP 6j ,.•� <br /> Uv�� (,G`C{A <br /> AccouNTADDREss for fees and charges OWNER FACILITY/BUSINESS TH ARTY BILLING <br /> RI LIA NG AND CONI PLIA NCE ACKNOWLE W;111 ENT: 1,the undersigned Applicant,certify that I am the(honer,Operator,or Authorized. ,e it of th•' s- end 1 acknoNledge that all <br /> PE2111T FEF_v,PENAL77Es,EN/'ONCF_A17_'NT C7/:IR(il•:S and/or HOURLY CIIARQ1J'associated with this operation will he billed to nre at the address identified above as the A('coy,'VTAnnRb-'a <br /> for this site. 1 also certify that all information provided on this application is true and correct;and that all regulated activities will be performed in accordance with all applicable SAN <br /> JOAQUIN COUNTI'Ordinance Codes and/or Standards and STA 7'E and/or FEDERAL.Laws and Regulations. As the undersigned owner,operator,or agent of the property located at the <br /> above facility/site address, 1 hereby authorize the release of any and all results and environmental assessment information to SAN JOAQUIN COUNTY ENVIRONMENTAL <br /> HEALTH DIVISION as soon as it is available and at the same time it is provided to me or my representative. <br /> PLEASE PRINT _ <br /> APPLICANT NAME � ^ SG�2 r, SIGNATURE <br /> TITLE <br /> �c DRIVER'S LICEN # <br /> Approved ByOate Accounting Office Processing Completed By Date 09 It <br />