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San Joaquin County Environmental Health �artment <br /> GREEN FORM <br /> DATE MASTER FILE RECORD INFORMATION YYMFR" <br /> SumcneocaRFrsv PRn rrcc nmv UNIT IV�5 <br /> OWNER FILE <br /> COMPLEM IHEFOLLOWING PROPERTY OWNERINADRMA rMN; CMFCK( OWNER CURRZNDYMx w END <br /> PROPERTY OWNER NAME ROOr,e-- <br /> Ml Last <br /> BUSINESS NAME — SOC SEC/TAX ID At <br /> Owner Home Address DRIVEa's Lvx iN # <br /> city STATE ZIP J fJ <br /> Owner Mailing Address <br /> Mailing Address City U/I /l/ 'A l Vr�,�I tD state R Zip �S sir <br /> 3Yp.1xlturzsFRSNm v`1... til I l l t' <br /> coRPgrATmN❑ INDRIDUAWL PARTNERS!®❑ Fm AGENCY OrxER❑ <br /> FACILITY FILE <br /> Fsm To At CROSS REFID# ACCOOM ID At INV# <br /> COMP10F 7NEFOLLOWING <br /> Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YEs ❑ No ❑ <br /> Is this an OUSTING Business LOCATION but a NEW TYPE of regulated Business? YEs El No ElBIISQlE6/FAmIrY/SIZE NAME I C I ` e 11 * I o <br /> SIrE AOOPES (p 1�, VV �3Ct Y 11nn I n e r S '�l StmE# BO pxoxE O <br /> Cm 'I STATE <br /> Iaipllg Addres IfD RE aci/ityAddress Attention:or Care Of folvto Q <br /> VVOO�jI <br /> Mailing Address CitySSTATE ZIP it GI X14 �ti C� <br /> THIRD PARTY BILLING INFO: Camp/ete if Billing Party is different from Property Owner or Facility Operator identified above. <br /> BUSINESS NAME Attention:aOf / <br /> Malting Addre- I PNONE <br /> Cm a_i STATE ZIP <br /> Accoui.Aaaaf.Y for fees and Charges OWNER FACILITY/BUSINESS THIRD PARTY BILLING <br /> 1,the undersigned Applicant,certify that I am the Owner,operator,or Authorized Agent of this Business,and 1 acknowledge that all PERM/TFZES, <br /> PENALnaS,EHPORCE ,WCILIROES and/or NOURLYCHAM,ES associated with this operation will be billed tome at the address identified above as the ALY U"AUDRCSe for this site. 1 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 COUNry 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 authorise 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 reprowntative. <br /> 1 pP�Feo PRIM <br /> APPLICANTNAME �. IQ 11�L�/� �,o��V SIGNATURELICENSE <br /> g y <br /> TE UU l'W ' (DPIIOTOWPY REQUMD)TITLE <br /> APprwed BY Dobe Atcountirg Office Processing Completed By Dale <br /> 29-02-002 April 25,2003 <br />