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San Joaquin County Environmental Health Department <br /> GREEN FORM <br /> DATE j Ito MASTER FILE RECORD INFORMATION "MFR" <br /> cxAnED ADcA9 MRFHEI HsFna1 Y OWNER ID# CASE# UNIT IV <br /> OWNER FILE <br /> CompLETF 7HEFOLLOW/ING/PROPERTY OWNER INFORMA710N; Of£arTF OWNER[Lrta£N/a+r�onFn£wmf END <br /> PROPERTYOWNERNANE / /.L PHONE <br /> `/1111 First / MI'7� g Last <br /> 6115ME55 <br /> NAME c� AG.I of st.. _ //U J/„rl,/`/!'S Sx SK/TM[D# <br /> Owner Hone Address //�0 . rw'.Pl�(/ Ql/ CIV (" DRIVER'S LICENSE TV <br /> city ' STATE C,4 21P I:S Z <br /> Owner Mailing Address <br /> Mailing Address City stow Zip <br /> TYRE WE nwNF (r� <br /> CORPORATION❑ INOWm1taL❑ PARTNERSHIP FED AGENCY OTHER.6L <br /> FACILITY FILE <br /> FAQLRY ID#1= <br /> CRoss REE ID At ACCOUNT ID# INN# <br /> Compwm 7NEFOLLOWINBUSINESS I FACILM I SITE N A7IONF <br /> Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? Yes ❑ No R <br /> Is this an EyrnmNG Business LOCATION but a NEWTYPE of regulated Business? YEB ❑ No <br /> M � <br /> BUSESS/FACRIIY/STT[NAME ,s 7 <br /> Sum#�-T//�� BUSMESS PHONE <br /> QTY ^. STATE/ [_/ I8 qV 20 3 <br /> BOARR <br /> D Of SUMERYLSOI Dtsrggcr LDUTwn Coce nEY1 KEY2 L-/-v <br /> Mailing Address M IENTIromllAddress _l "7oA ntbn:w Care Of( Q <br /> taco C24 t ' ou � �n �uhs�ui� <br /> Mailing Address City v`t/'.`7 �Q STATE r,Q W (:71IL <br /> sic CODE f APN# t/l J CAMMENT: <br /> THIRD PARTY BILL/ING INFO; COMPlete/f Billing Party isditferentfmm Property Owner or Facility Operator idenbfiedabove. <br /> Busxnrss NAME f ,� ) n � � ^ _� ,�^„/_A rdMn:orCare Of (trp wsuay <br /> er <br /> a� U21112 <br /> Mailing Address _,1E^ 1 G (����v/ R�L� PH�E <br /> CITY if - / STATE �( J(`C zm eD <br /> Accau rrannaLW for fees and charges OWNER FACILITY/BUSINESS —THIRD PARTY BILLING <br /> RIP VINE AND COMPI IANCT APRNOM EDGMENT: 1,the undersigned Applicant,certify that 1 am the Owner,Operator,or Autharlu✓Agent of this Business,and 1 acknowledge that all PERNff F££S, <br /> P£NALRFS,ENFOR ENTCMAR and/or HOUN.YCHAnQ£5'associated with this operation will be billed tome etthe address identified above"the 4( (NTADDRFSF for this site. I sho certify that <br /> all information provided on this application is true and correct;and that aft regulated activities will be performed in accordance with all applicable SAN dOAQUIN COUNTY Ordinance Coda 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 relesse of <br /> any and all results and environmental assessment information to SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as son n ss it h available and at the sam'ee TTomJe�d' <br /> provided tDme N Mrepresentative. <br /> N `' �nP iASE PnrMr SIGNATURE <br /> APPLICANT NAME , I /(/` C{'(, <br /> ?RLE `/�e� DRIVER'S LICENSE# <br /> Tzao) <br /> VER'S REQUIRED) <br /> Approved By Date Accounting Offer Processing Completed BY DaM <br /> 2&02-002 Apn125,2003 <br />