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i <br /> San 11-6jin County Environmental Health .*artment <br /> ®ATE MASTER FILE RECORD INFORMATION "MFR" GREEN FORM <br /> SHADED AREAS FOR EHD USE ONLY OWNER ID# D0IS�2� CASE# UNIT IV <br /> OWNER FILE <br /> COMPLETE THEFOLLOW/NGPROPERT`'Y OWNER/NFORMAT/ON: CHECK/F OWNER CURRENTLYONF/LEW/TH EHD <br /> PROPERTY OWNER NAME �p. 2,02-9c 6Acau J <br /> PZ <br /> HONE a g- tf?- m-( <br /> Oy C v)IIL o <br /> First Ml Last <br /> BUSINESS NAME Tl.� SOCSEC/TAx ID# <br /> Owner Home Address 3"I a' µacv �'P �f'v LP ' �^C�t k'��N 9 5-2--2' t 0.Ca N J DRIVER'S LICENSE# <br /> ,v, c <br /> city 5-L.-C*-e-" c :4,) g 1� F'lan�dw�IG�J CA C- <br /> - <br /> Owner <br /> o L STATE ZIP <br /> Owner Mailing Address '5CLWle 04 t7Wm-ew I'T,asuti�[ a`do�,t'tt-S <br /> Mailing Address City State ZIP <br /> CORPORATION❑ INDIVIDUAL❑ PARTNERSHIP❑ FED AGENCY❑ OTHER <br /> FACILITY FILE <br /> �Lrrylp# CROSS REF ID# E--]FACCOUNT ID# �O n INV# 4 3 S3 <br /> COMPLETE THEFOLLOW/NG B41USINESS/FACILITY/SITE/NFORM4770N' s <br /> IS this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPT.? YES ❑ No ❑ <br /> IS this an EXISTING Business LOCATION but a NEW TYPE Of regulated Business? YES ❑ No ❑ <br /> BUSINESs/FACILrrY/SRE NAME <br /> SITE ADDRESS !" 0.) "T y� ! / � SUrTE# BUSINESS PHONE <br /> CITY \ Cs�t STATE LP r4), <br /> BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEY1 KEY2 r; <br /> Mailing Address KD/FFERENrIrom FaclUtyAddress Attention:or Care Of(optional) J <br /> I <br /> Mailing Address City STATE ZIP <br /> SIC CODE I APN# [COMM—.- <br /> THIRD PARTY BILLING INFO: Complete ifBilling Party is different from Property Owner or Facility Operator identifledabove. <br /> BUSINESS NAME C I'J j rr'Gvc - TwP'r -&,,A". 5 Attention:orCare Of(oplyonal) 2 70 <br /> Mailing Address Z 12� � �w �/Q tr _( PHONE I 6 Z j- 3 o <br /> CITY y `o Y STATE IL <br /> !may, ZIP I l G�.9 <br /> AccouNTADDRecs;for fees and charges OWNER FACILITY/BUSINESS "�,THIRD PARTY BILLING <br /> BILLING AND COMPLIANCE ACKNOWLEDGMENT: 1,the undersigned Applicant,certify that I am the Owner,Operator,or Authorized Agent of this Business,and I acknowledge that all PERMIT FEES, <br /> PENALTIES,ENFORCEMENT CHARGES and/or HOURLY CHARGES associated with this operation will be billed to me at the address identified above as the ACCOUNTADDRESS 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,operator,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 DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my representative. <br /> APPLICANT NAME cIC G PLEASE PRINT L,I C��.�.,� SIGNATUR : �� Q `t <br /> TITLE {('� DRIVER'S LICENSE# <br /> _led COPY REQUIRED) ��� T LL <br /> Approved By Date Accounting Office Processing Completed By Data <br /> 29-02 10/12/07 MASTER FILE RECO -GREEN <br />