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San Joaquin County Environmental Health Department <br /> DATEGREEN FORM <br /> MASTER FILE RECORD INFORMATION "MFR" <br /> P' Jfl <br /> OWNER ID# � 1 l 1:: #. U <br /> CASENIT I�/ <br /> (OWNER FILE <br /> COMPLETE THE FOLLOWING PROPERTY OWNER INFORMATION: CHECKIF OWNER CUHRENTk YON FILE Wv H EHD <br /> PROPERTY OWNER NAME PHONE 2oq_ g 3 �I C' O <br /> First Ml Last L O JO <br /> BUSINESS NAME <br /> �l rlwcY ( Clomout44t5 LL= <br /> SOSEC/TAX ID# <br /> Owner HomeAddes 3120 0.0 6 IUCs ,Ic A # <br /> city Irc.c. <br /> STA�q Zza <br /> Owner Mailing Address <br /> e <br /> Scc LG <br /> Mailing Address City State Zip <br /> trot nr nw.mns.TP <br /> CORPORATION❑ INDMWAL❑ PARTNERSHID❑ FED AGENCY El ORIER❑ <br /> FACILITY FILE <br /> FACILITY ID# Ii -� I CROSS REF ID Account ID# t ,. _ INV# <br /> V i <br /> Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? Atw4r No ❑ <br /> IS this an EXISTING Business LOCATION but a NEW TYPE Of regulated Business? VES <br /> BBSINESS/FAaLm/SIZE NAME IIf <br /> M DtAv. � h rIDU. — <br /> SITEADDLES 171 C) 3 W <br /> SUITE At BUstrasss PHONE <br /> CM i( C <br /> BOARDOFSUPEft L RDISmIcr LOCATION CODE KEYS KEY2 <br /> Mailing Address ifOIFFERENTfrom FaoiityAddresr Attention:or Care Of(optional) <br /> A <br /> Mailing Address City r'Gc� ST TE <br /> c2� �i534/o <br /> SIC CODE APN# Coss`E r; <br /> THIRD PARTY BILLING INFO: Completed Billing Party isdifferentfrom Property Owner or Facility Operator identified above. <br /> BUSINFSSNAME Attention:or Care Of (aptitstra/J <br /> COYLjOr JC v ICT -q W'Illcl4 <br /> Mailing Address I'S$ ['" L c 1 1✓cit. JL-EL't� �f, PHONE LD9—Z3q—OSI'3 <br /> Cm -Mock7kV" <br /> A 45206 <br /> ACCQUN a^^^«<for fees and charges OWNER FACILITY/BUSINESS THIRD PARTY BILLING <br /> Biu INC AND COMP IANLE Aruunw Pnr : 1,the undersigned Applicant,certify that I am the Owner,Operator,or Authorized Agent of this Business,and I acknowledge that all PERanTFEes, <br /> PEN Tl B,ENFORCEMENTCHARGES and/or Hout YCHARGU associated with this operalion will be billed to meat the address idendBed above as the ACCOEM4DDRET for this site. I also certify that <br /> all information provided on this application is true and correct and that all regulated acdvitics will be performed in accordance with all applicable SAN JOAQUIN COI Ordinance Codes and/or <br /> Standards and STA-E 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 author@z the release of <br /> any and all results and environmental assessment information to SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT u an as It Is available sad at the same date it is <br /> provided to me or my representative. <br /> APPLICANT NAME /L���ilEASF PRIIir SIGNATURE <br /> DRIVER'S LICENSE# / r <br /> (PHOTOCOPYREOUIRED) <br /> Approved BY Data Accounting Office Processing Completed By - <br /> 29-02-002 April 25,2003 <br />