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San Jouin County Environmental Health&artrnent <br /> DATE D y MASTER F9LE RECORD NFORMATION 69MFR <br /> 99 <br /> GREENFORM <br /> SHADED AREAS FOR EHD USE ONLY OWNER ID# CASE# U" v�T <br /> OWNER FILE <br /> COMPLETETHEFOLLOW/NG PROPERTY OWNER/NFORMAT(ON: CHECK/F OWNER CURRENTLYONF/LEW/TH EHD <br /> (zp. <br /> 2-Q2-8 I -A PHONE 2�q""Itp?' I <br /> PROPERTY OWNER NAME L v)IIL o <br /> First MI Last <br /> BUSINESS NAME SOC SEC/TAx ID# <br /> 311 I-`a41A S-t. LF . S-t-cH � , 9'5-2-'Z LR`c <br /> Owner Home Address DRIVER'S LICENSE# <br /> STATE � <br /> c -Qz G <br /> City L� >^ G f `7 <br /> Coln .) � t 111 <br /> . o 95ao] <br /> 1� f_ _�1�y�(�J ZIP <br /> Owner Melling Address Sckwte 0-S Q1/ 1A.P. <br /> 3N <br /> Mailing Address City state ZjP <br /> CORPORATION❑ INDIVIDUAL❑ PARTNERSHIP❑ FED AGENCY❑ OTHER <br /> FACILITY FILE <br /> ------------------ <br /> FACILITY ID# CROSS REF ID# ACCOUNT ID# INV# <br /> COMPLETETHEFOLLOW/NG BUSINESS I FACILITY/SITE/NFORMAT/ON. <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 aNEW TYPE Of regulated Business? YES ❑ No El <br /> BUSINESS/FACILITY/SITE NAME uN L5-h-4 A.ob,?jLx- 3410~-A <br /> I, T <br /> SUITE# BUSINESS PHONE <br /> SITE ADDRESS �aCeN is O_ M �V�V`,L� J.�• <br /> CITY cl_ _� STATE LP <br /> BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEYS KEY2 <br /> Mailing Address KD/FFERENTfrvm Facll4AIddress Attention:or Care Of(optional) <br /> Mailing Address City STATE ZIP <br /> SIC CODE APN# COMMENT: <br /> THIRD PARTY BILLING INFO: Complete ifBilling Party is different from Property Owner or Facility Operator identified above. <br /> BUSINESSNAME Y�N Tjl��t t �4"'V 5 Attention:orCareOf(aptlona/J 27G� C <br /> Melling Address Z 1 Z mow,t�vcs (�+/¢. )�� ^I PHONE "t �'g f-- 6 �-o <br /> Cm STATE C A ZIP Q lL�� <br /> GT.�tro Yd "'r 1 t�f <br /> ACCOUNTADDRESS for fees and Charges OWNER FACILITY/BUSINESS THIRD PARTY BILLING <br /> BILLING AND COMPLIANCE ACKNOWLEDGMENT: I,the undersigned Applicant,certify that I am the Owner,Operator,or Authorized Agent of this Business,and I acknowledge that an PERMLT 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 ACCOUNT ADDRESS 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. P <br /> `cls PLEASE PRINT e Ct�.oti SIGNATOR <br /> APPLICANT NAME � <br /> DRIVER'S LICENSE# <br /> TITLE �u C; ►� (PHOTOCOPY REQUIRED) <br /> Approved By 1 Date // Accounting Office Processing Completed By Date <br /> MASTER FILE RECORD-GREEN <br /> 29-02 10/12/07 <br />