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San Jo in County Environmental Health C )artment <br /> GR--EN FORM <br /> "" MASTER FILE RECORD INFORMATION IIMFRrr <br /> SaAI^cnna FMD wF run OWNER ID# - CASE# UNIT IV <br /> OWNER FILE <br /> COMPLETE rHEFOLLOWINGPROPERTY OWNER INFORMATION; /� CHED[IF OWNER CNRRENTLYONFFLE NY EHD <br /> PROPERTY OWNER NAME A a� / C!e}-f2-AJ r.G PHONE 2 01: q46- <br /> 6 6 7O O! <br /> PK E4 tSIp 6 Firsr MI / nLasst T <br /> BUSINESS NAME$�!d K Q"aN �r6 rz i,,v i.L 't �r(�r,��tz t `z Z SOc Sec/TAx ID# <br /> c <br /> Owner Home Address DRNWS LICENSE Is <br /> city STATE ZD` <br /> Owner Mailing Address 1176 Aj .-7(LO 4 ID <br /> Mailing Address City r-d�!<T�N 6 '`ice Zip <br /> r <br /> 'rvoFnFnw FRCHTP <br /> CORPORATION INDMDUAL❑ PARTNERSHIP❑ FED AGENCY❑ OTHER❑ <br /> FACILITY FILE <br /> FACILITY ID# CROSS REF ID# ACCOUNT ID Al INV# <br /> COMPLETFTHEFoLLowrNG BUSINESS I FACILITY I SUE INFORMATION., <br /> Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ NO19, <br /> Is this an EIasTING Business LOCATION but a NEW TYPE of regulated Business? YES ❑ No <br /> BUSINESS/FA NAME CAtZofn//4L q Vg t2(2 Cf20. I-1rV6 <br /> SAE ADDRESS SURE# BUSINESS PHONE <br /> N A —26of Na2r/I- or l/vtS2SEc'r(�A/ dP <oitZD4FaG- /t(/�. <br /> f4N IEf2 <br /> CITY ST-0c K r6N RTE ZD` S�rj' <br /> BOARD OF SUPERVISOR DISTRICT LOGTION CODE KEYI REYZ <br /> Mailing Address ifDIFFERENrI om Facility Address Attention:or Care Of(ophona/) <br /> Mailing Address City STATE ZD` <br /> SIC CODE APN# COMMENT; <br /> THIRD PARTY BILLING INFO: Complete if Billing Party is different from Property Owner or Facility Operator identified above. <br /> BUSINESS NAME {� S} Attention:orCam Of (optional) <br /> PcD12fL f}Ssact /�?'r�•Jn' (1/�. <br /> Mailing Address O00 5Xp(-Ct26`` DA. t-5- PHONE /i, `�55 <br /> 7 <br /> ` 1 <br /> 6u <br /> zip <br /> C' <br /> SO �Ci 951n7 <br /> wCCn.rMr e.,.,ovcc for fees and charges OWNER FACILITYIBUSINESS THIRD PARTY BILLING <br /> R Nn COMPt rANre APKNOWLFDCMENT: L the undersigned Applicant,certify that 1 am the Owner,operator,or Authorized Agent of this Business,and I acknowledge that all PMM17 FEES, <br /> PEVA xrx,,ENFuR EmEM CHARGES and/or HOURLYCHARGES associated with this operation will be billed tome at the address identified above as the AmOIW AD AREW 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 HEALTH DEPARTMENT as so a available and at the same time it is <br /> provided to me or my representative /p•(I1K//// <br /> PLEASE PRINT SIGNATURE <br /> APPLICANT NAME /}LfF IU C44U�ClF(LL- <br /> TITLE DRIVER'S LICENSE# <br /> GG-0'-QG(rf'r (PHOTOCOPYREOUIRED) <br /> Approved By Date Accounting Office Processing Completed BY Date <br /> 29-02-002 April 25,2003 I Y� L l t 1L <br /> N <br />