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oa I a o <br /> t I4ri' I 6LYCawwaaci, n.�, <br /> GREEN FORM <br /> DATE MASTER FILE RECORD INFORMATION "MFR" <br /> $HADEDARUSIOREHO G Y UNIT IV <br /> OWNER FILE D'�1p57`7 Z <br /> COMPLETETHEFOLLowINGPROPERTY OWNER INFORMAT)ON.' Ci/ECKIF OWNER CuRRENrzroNFiLEwmEHD <br /> PROPERTYC 1�I `// PHONE <br /> OWNER NAME LEO 1`t. Y " I PI ;209-y(a q- (i 7(a8 <br /> Fly MI <br /> JLx- <br /> BUSINESS NAME - SOC SEC I TAX ID'r <br /> �• vO I t1 11 SOH <br /> Owner Home Address to 2 I r�Z i✓J(�C.L�1 4't-�/ C.,e C I e. DRIVER'S LICENSE# <br /> city 5 Q ENVIRONMENTAL HEALTH STATE zip cl S 219 <br /> y Dct<-r Dw <br /> Owner Mailing Addreaa •J C Am I- As 44o✓e- <br /> Mailing Address City 6 A £ <br /> states Ip /3ovF <br /> CORPORATION O NDIVIDUAL❑ PARTNERSHIP Or FED AGENCY❑ OTHER❑ <br /> 7 (o FACILITY FILE <br /> FACItrr2l Ro RMMMIMow ACCoufrID' - <br /> COMPLETETHEFOLLOWING BUSINESS/FACILITY/ SITE INFORMATION: <br /> IS this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DIWSION? YES ❑ NO Sr <br /> Is this an EXISTING Business LOCATION but a NEW TYPE of regulated Business 9 YES ❑ No <br /> BUSINESS/FACILITYISITE NAME <br /> SITE ADDRESS SUITE# BUSINESS PHONE <br /> I DOC C19 C h c. >+t — LA-Dc I '�L o°I 463 16 8 2 <br /> CITY5 L �.^ STATE ZIP fl <br /> Mailing Address if DIFFERENT from Facility Address Attention:or Care Of(optional) <br /> s -o c. � <br /> Mailing Address City $ STATE LP y1S 6, Was�. f. �vn Street oeAiA 9.S03 <br /> Ids on go W <br /> THIRD PARTY BILLING INFO: Comp/etc if Billing Party is different from Property Owner or Facility Operator identified above. <br /> BUSINESS NAMEAttention:or Care Of (opdonal) <br /> CasEDt e.C11A;CC-t` co. sv S STEVO 'Art <br /> Mailing Address ,L 0 <br /> X441 W. 2 PHONE S-r. �' <br /> CITY STATEA- ZP y52,F/ <br /> AccouNrAaaREss for fees and charges OWNER FACILITY/BUSINESS THIRD PARTY BILLING <br /> BILLING AND COMPLIANCE ACKNOWLEDGMENT: 1,the undersigned Applicant,certify that I am the Owner,Operator,orAuthoriudAgent of this Business,and I acknowledge that all <br /> PERMTr FEES.PENALTIES,ENFORcFmF CmARGEs and/or HOURLY CmRGES associated with this operation will be billed to me at the address identified above as the ACCOUMADDRay <br /> for this site I also certify that all information provided on this application is true and correct;and that all regulated activities win be performed in accordance with all applicable SAN <br /> JOAQUOI COUNTY Ordinance Codes and/or Standards and STATE and/or FtDERAI.Laws and Regulations. As the undersigned owner,operator,or agent of the property located at the <br /> above facility/site address• I hereby authorize the release of any and all results and environmental assessment information to SAN JOAQUIN COUNTY ENVIRONMENTAL <br /> HEALTH DIVISION as soon as it is available and at the same time it is provided to me or my represmmtive <br /> W <br /> a��LLPLEASE PRINT �'/ <br /> APPLICANT NAME C I.t'r S (1✓ r S SIGNATURE '14 <br /> DRIVER'S <br /> r f DRIVER'S LICENSE# <br /> TITLE C.n L) r r o n M! PT"a l M 4 n C, !5 t r Io'Wnmrnw REoulaEDl ` <br />