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San Joaquin County Environmental Health Department <br /> GREEN FORM <br /> DATE MASTER FILE RECORD INFORMATION "MFR" <br /> <neD[D aa[.c[Da PMD ii«na,v OwxER ID# —7 �—j cASE# UNIT IV <br /> OWNER FILE <br /> COMPLETE THE FOLLOWING PROPERTY OWNER INFORMATIO1N�; ONECRIF OWNE{/R�CURREHTZYONFrLEH`nH EHD <br /> El <br /> PROPERTY OWNER NAME t 5 �v ;es PHONE �VC�- lyz —y? S C' <br /> 111YPP��� First MI Last JJ <br /> BUSINESS NAME �dI 1 �'"ick a 1i &A1 SOC SEC/TAX ID# <br /> f G1,U1( _ <br /> Garner HomeAddress / <br /> }1./�2 ,vo/ S� ��� r�S 7 7_„�� E�� DRIVER'S RCENSE# <br /> City \ 1 Ja C� 9 3 o H ll A n STATE ZIP <br /> Owner Mailing Address O <br /> Mailing Address City J p l-� r` _ State IP <br /> S-FocF r�p,..1/.�'�nviC�; C�- %s2o/ <br /> aD.nwDraain <br /> CORPORATION INDIVIWAL❑ PARTNERSHIP❑ FED AGENCY❑ DIMER❑ <br /> FACILITY FILE <br /> FACILITY ID# CROSS REP To At ACCOUNT ID# 33 't'q INV# 1,r� 2-r) L <br /> COMPLETE THE F L` NF MA7T r I L -J <br /> Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ No ❑ <br /> IS this an EXISTING Business L/ r <br /> O�CATION but d NEW TYPE Of regulated Business? YES ❑ No El <br /> BUSINESS/FACRSTY/SHE NAME (L <br /> YJt 'A '� `t <br /> SIDE ADDRESS 'Z �1 D Slr tY` ` Q R I SURE# BUSINESS PHONE <br /> J / <br /> CITY C p.. q ATE L IIP <br /> BOARDOFSUPERVLSORDISTRICf I LOGTION CODE KEYS REYZ <br /> Mailing Address ifDIFFERENTMDrn FaaMily Ydress Attention: r Ura Of(opt/onaQ <br /> P•0. Aox 1 S—I <br /> Mailing Address City C 1..�kfotj Cj q.5- z o t STATE ZIP <br /> s[C CODE J �ANPN# Il/ (� �p COMMENT: <br /> THIRD PAR"BILLING INFO: Completeif BillingPartyis different from Property Owner or Facility Operator identified above. <br /> BuslNFss NOME e / Or Atteridon.wCar Of (op0'orraQ <br /> ( l3 <br /> Mailing Address ('��O I /,./ ( j { f `r PHONE S/D _ y�_ 33 <br /> V l7"T/ li c)']` J STATE zip <br /> Core <br /> ^^=,m;E^^^"'K for fees and charges OWNER FACILffy/BUSINESS THIRO PARTY BILLING <br /> Rn I INC.AND COMPI E NCE ACRnnW1aca:MFNT: 1,the undersigned Applicant,certify that 1 am the Owner,Operator,or Authorised Agent of this Business,and I acknow g at all PERHn PEEt, <br /> PENALRES,ENFORCEMENT CHARGES and/or HOURLYCH^RGEs associated with this operation will be billed to me at the address identified above as the ArrOUNr AnnRvee for this site. 1 also certify that <br /> all information provided on this application is hue and cormt;and that all regulated activities will be performed in accordance with all applicable SAN JOAQVIN 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 aff 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 /> PLEASE PRINT n Q <br /> APPLICANT NAME SIGNATURE ( fvO�LAAAU <br /> TITLE 1�.. DRIVER'S LICENSE# <br /> Ut .1({jl/iYI (PHOTOCOPY REOUIRED) <br /> Approvetl BY Date Accounting Office Processing Completed By Dale l7 <br /> 29-02-002 April 25,2003 <br />