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San Joa Win County Public Health Services Environmental Health Division <br /> - GREEN FORM <br /> DATE MASTER FILE RECORD INFORMATION "MFR" <br /> • swoon pN. .EHDVVOatr OwNERID# D , , CASE# UNIT IV <br /> OWNER FILE <br /> CHEIXIF OWNER NlrxEnnrox FnE wJniEHD ❑ <br /> CoMpLETETHEFo[LowiNGPROPERTY OWNER INFORMATION: <br /> PROPERTY OWNER (Sob f <br /> BLIr' rico <br /> NAME <br /> PHONE (109) `/LG - X z1S <br /> M�LyAGI �. II VA+Ga (2Of� YL6 - Y9S3 <br /> �//•1 nFirst MI last r.� <br /> nTaEss NAME $OC SEC/TUl ID# <br /> Owner Home Adddiress /l/7,KYOG Woods:da DRrvm's LICENSE <br /> city STATE ZyP 9s1a7 <br /> STo ckTon GA 9S2os <br /> owns Plainng AtldrPSa <br /> Mailing Address City State Lp <br /> TYPE of owNERSHm <br /> copiO arson❑ INDIVIDUAL PARTNEaSH[P❑ M AGENCY❑ OrHER❑ <br /> FACILITY FILE <br /> FACILITY ID# 'Q CRoss REf ID# AccouxT ID# BO_..a l 3 / D.# - <br /> COMPLETETHEFOLLOwING BUSINESS FACILITY / SITE INFORMATION: <br /> Is this a NLw Business LocATION not previously regulated by the ENVIRONMENTAL HEALTH DIVISION? Yes ® No ❑ <br /> Is this an E)CESfING Business LoranoN but a Nm TYPE of regulated Business�7 YES ❑ No ❑ <br /> BUSINESS/FACILITY/SITE NAME <br /> 61e.aso. Park s 77ES <br /> SIre ADDRESS Sum# BUSENEss PHONE [204) 937-" <br /> .(:lock o b 1 7p oivtia 5frcG7- TETr/eeT `• nn . STr'eeT <br /> CITY STATEq �gszC,; <br /> G1�rCTon <br /> IIBOARD OF SUPERVISOR DStRICf. ..l .I. LQcATION CODE I.. I KEYI- - I KEY2 <br /> Mailing Address ifDIFFERENThom Favi/ityAddress Attention:or Care Of(optional) <br /> C 'TX 4 ST ckr gec/ev lod, t T. FA 3o t' I! 17 Aor do 4t'Te Zoo % �.ls. K'TTs U/lker <br /> Mailing Address City STATE ZIP ej f'ZOZ <br /> sr,kr�„ <br /> SIC OM <br /> CODE :. ;• APN# .CMENT: <br /> THIRD PARTY BILLING INFO. Completeif Billing Party is different from Property Owner or Facility Operator identified above. <br /> Busmfss NAME Attention:or Care Of (optiowl) <br /> '/n.[, Tw;n;n /.a(oararorles , <br /> MailingAddress PHONE 1559) .T6u— ;0 <br /> e252J Fresno 5%rLtT <br /> Cm STATE ZIP Ares <br /> Cff 9371/ <br /> ACCOVM for fees and charges OWNER FAciLITYIBUSINESS IRD PARTY BILLINC�a <br /> BILLING.t D COMPLIANCE Acx40WLEDG.teN'r: L the undersigned Applicant,certify that I am the Owner,Operator,or Authorized Agent of this Business,and I acknowledge that all PERSHT FEES, <br /> PENALTIES,ENFORCEMEVTCHARGES and/or HOGRLTCHARGES associated with this operation will be billed to me at the address identified above as the ACCOL]TADDrt for this site. I also cerdfr that all <br /> information provided on this application is true and correct;and that all regulated activities will be performed in accordance with all applicable SAN JOAQLIN CDurry Ordinance Codes and/or <br /> Standards and STATE and/or FEDERAL Laws and Regulations. As the undersigned owner,operator,or agent of the properly located at the above ft e{{{dddddd555���IIliii������...���FFFjjj���b authorise the release Of <br /> any and all results and environmental assessment information to SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DIVISION as soon asFt if�}' � Iufd ItLt 'TiA�it Is provided to <br /> me or my representative. V U I IUUUI fL Ti <br /> N L <br /> PLEASE PRmr <br /> APPLICANT NAME ��''��i.l4 f l�, n/CIG /- SIGNATURE <br /> // /" !! .ot DRIVER'S LICENSE# <br /> TITLE F.ry v. /c/l.s/JjI.. � (P110TOCO YREQUIRED) <br /> Approved BY Date - A_ Aornunting Office Processing Completed Bin Date <br />