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D <br /> San Joaquin County Environmental Health Departmerip <br /> DATE <br /> �y MASTER FILE RECORD INFORMATION."'MFR" GREEN FORM <br /> MAY 2 5 2004 <br /> `��d�►r�;.�NIT, IV <br /> OWNER FILE <br /> COMPLETE THE FOLLOWING PROPERTY OWNER INFORMATION; YT <br /> CHECKIF OWNER CURRENTLYONFZLEWIrH EHD El <br /> OWNER NAME /.�/]�j) /? J cy'1 <br /> fT/�J C PHONE <br /> /Iy7First MI I <br /> Last <br /> BUSINESS NAME /' <br /> L��1�/!�✓/7_ //� r � <br /> 1Sc- / L � 7oSEC/TAXID# <br /> Owner Home Address <br /> DRIVER'S LICENSE# <br /> clry <br /> STATE Zg <br /> Owner Mailing Address <br /> Mailing Address City �<�n /�5it�t / P <br /> L <br /> 3)m tonwwFP6RD <br /> CORPORATION❑ INDIVIDUAL❑ <br /> PARTNERSHID FED AGENCY❑ <br /> OTHER❑ <br /> FACILITY FILE <br /> FAQLnY <br /> D# CROSS REFID# <br /> ACCOUNT ID#:. INV# <br /> T7717. 711- <br /> ca"PIUM THEF LL00WG Rl ISINF--q-q-1 FAciunummLA-FAMMATT N' <br /> Is this a NEw Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES No ❑ <br /> Is this an EIaSTING Business LOCATION but as NEW TYPE d regulated Business? J YES ❑ No ❑ <br /> BUSINt35/FACIISTY/SITE NAME /"I may. /��/✓�(.l� ,�J� /,(���,��, , I �f/1�' ` l��'�7 <br /> SITESADDR-F-% t!/� )7 ll"`j&-X1(� C � I �(ii/� 5/Yr t7/r,4/Yly_ f/J` SUITE At BUSINESS PHONE <br /> CITY <br /> . STATE/SII ZIP <br /> ,7 <br /> Mailing Add r ifDIFFERENrfrmn FadlityAddre" Attention:or Care Of(optional) <br /> a <br /> Mailing Address City C)—��f/ �► <br /> SYATE/�4 ZIP <br /> THIRD PARTY BILLING INFO: Completed Billing Party is different from Property Owner orFacility Operator identified above. <br /> BUSINESS NAME Attention:or Care Of (optional) <br /> Mailing Address PHONE <br /> CITY STATE ZIP <br /> d=QU9rw0nncea:for fees and charges WNER FACILITY/BUSINESS THIRD PARTY BILLING <br /> HILT 1NG AND COAIPI IANCR ACI(IYOWI EnGMFNT: I,the undersigned Applicant,certify that I am the Owner,Operator,or Authorized Agent of this Business,and I acknowledge that all PERMITFEES <br /> PENALTIES,ENFORCEMENT CHARGES and/or HOURLYCHARGES associated with this operation will be billed to me at the address identified above as the ACCOt/NTAnnRFCQ 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 IIEALTH DEP TM as oon a is ail�t the same time it is <br /> provided to me or my represen Uve. <br /> APPLICANT NAME �2�%f'//"—(.' ✓ / 1/" LEASE P SIGNA E <br /> TITLE (DRrVEWS PHOTOCOPYREQt"SED) <br /> APPrwed By (� !b G y Date Aocoutiting Office Processing Completed By DatE <br /> 29-02-002 April 25,2003 <br /> Iwo, <br />