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02/09/2001 12:15 2094683433 FIFTH FLOOR PAGE 02 <br /> G - <br /> offil <br /> a <br /> I <br /> GREEN FORM <br /> DATE MASTER FILE RECORD INFORMATION "`MFR" EB _ 9 ;>�►U1 <br /> UNIT <br /> THIV <br /> $N0.DED A1tFA5 FOa EH()U5f Q11LY '?E ` - <br /> w <br /> n <br /> s <br /> OWNER FILE �ECKr" OWNI RGYIRREMtVON FILE WITH EHD <br /> COMPLETE THEFOLLOWINGPROPERTY OWNER MFORMATION; VV / (✓CJ — <br /> PROPERTY OWNER PHONE .21391 <br /> NAME <br /> First All last <br /> BUSINESS NAME SOC SEC/TAK ID# <br /> C-6141— <br /> Owner Horne Address DRIVER'S LICENSE# Q <br /> city + /n _ STATE ZSP <br /> 'rte✓ <br /> Owner Mailing Address <br /> Mailing Address <br /> TYPE OF OWNERSHIP ( <br /> CORPORATION❑ INDIDUAL❑ PARTNERSHIP❑ PED AGENCY El OTHER❑ <br /> IV <br /> FACILITY FILE . <br /> _r <br /> COMPLETE THE FOLLOWING BUSINESS r FACILITY/ SITE INFORMATION; <br /> 15 this a NEw Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DIVISION? Y No <br /> Is this an Da STING Business LOCATION but a New TYPE Of regulated Business? YES No ❑ <br /> BUSINESSi FAQf1Tv/SITE NAME <br /> SUrrE# BUSINESS PHONE <br /> SITE ADDRESS <br /> CirY STATE ZIP <br /> Mailing Address if DIFFERENT from FacilityAddls Attention:or Care Of(aphonaQ <br /> Mailing Address City SFATE ZIP <br /> THIRD PARTY BILLING INFO: Complete if Billing Party is differentfrom Property Owner or Facility Operator identified above. <br /> BUSINESS NAME f� 6�4CW, Attention:or Care Of (optrona!) <br /> Mailing Address O � � C �� PHONE Oq 7 <br /> CITY t� r I`' STATE �P /`J OC(/ <br /> I V <br /> AccouNTADt]RE59 for fees and charges OWNER FACILITY/BUSINESS THIRD PARTY BILLING <br /> BILLING AND COMPLIANCE ACKNOW LEDGMENTt 1,the undersigned Applicant,certify that I am the Orvner,Operator,or Authorized Agent of this Business,and I acknowledge that all PERMIT FEES, <br /> PENALI•rES,ENFORCEMENT CNARGEs and/or HOI.RLY CHARGES associated with this operation will be billed to me at the address identified above as the ACCOu+vIADDBESS for this site. I also certify 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 JOAQUJN 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 herebv authorize the release of <br /> any and all results and environmental assessment information to SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DIVISION as soon a it is available and at the same tune it ft rovided to <br /> me or my representative <br /> PLPASF„PRINT <br /> APPLICANT NAME fO-q 4 j2e SIGNATURE <br /> DRIVER'S LICENSE# 7 77/ <br /> TITLE �i'(rps���Z/,P bu yam (PHOTOCOPY REQUIRED 1 <br /> Ca <br /> t <br /> �— - <br />