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"Jn County Environmental Health paartm,ent ' :.." <br /> DATE " <br /> r /5 MAS7--FILER RECORD INFORMATION 11MFR'S GREEN FORM <br /> c-� <br /> Saau�As_-w�ENDLSEOws OWNER ID# <br /> �E# UNIT IV <br /> OWNER FILE <br /> COMPLETE THE FOLLOWING PROPERTY OWNER INFORMATION; CHECKIF OWNER CURRENTLYONFILEWITHEHD <br /> PROPERTY OWNER <br /> NAME PHONE <br /> Firs( MI <br /> last <br /> BUSINESS NAME <br /> S,,,9-- �, � � i SOC SEC/TAX ID# <br /> Owner Home Address <br /> 3a DRIVER'S LICENSE# <br /> (;ity <br /> STATE . ZIP <br /> Owner Mailing Address �r J <br /> Mailing Address City _ <br /> State Zi <br /> TVDF OF nWNFDGHTD <br /> rnDDADAT nN TNhTVirum, ❑ DADTNFOCHTD F] <br /> FFh Al_FNr`V❑ ATHFD❑ <br /> FACILITY ID# CROSS REP ID# <br /> A <br /> Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? <br /> Yes ❑ No. <br /> Is this an E)asTING Business LOCATION but a NEW TYPE of regulated Business? <br /> ❑ <br /> BUSINESS/FACILITY/$ITE NAME YES No <br /> SITE ADDRESS �L <br /> 3 s-- <br /> /, n,�y�� SUITE# BUSINESS PHONE <br /> CITY l.�„�. u <br /> . STATE <br /> BOARD OF SUPERVISOR DISTTUCr I "LOCATION CODE <br /> Mailing Address ifDIFFERENTfmm FacdityAddress Attention:or Care Of(optional) <br /> Mailing Address City <br /> STATE ZIP <br /> �.r �t' � <br /> SIC CODE APN# COMMENT a <br /> THIRD PARTY BILLING INFO: Complete if Billing Party iS different from Property Owner or Facility Operator identified above. <br /> BUSINESS NAME <br /> Attention:or Care Of (optional) <br /> Mailing Address 3/� PHONE <br /> CITY 3 0 <br /> STATE ZIP <br /> Ar/•nttturd gs- for fees and charges OWNER <br /> FACILITY/BUSINESS (THIRD PARTY BILLING <br /> 13111 ING ANT)C QUE iANCr C Nrnvi rnr NarN1; I,the undersigned Applicant,certify that 1 am the Owner,Operator,or Authorized Agent of this Business,and I acknowledge that all PERMIT FEES, <br /> PENALTIES,ENFoRcEMEATCHARGES and/or HOURLY CHARGES associated with this operation will be billed tome at the address identified above as the ACrnnNTAnnercc 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 JOAQUnv 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,1 hereby authorize the release of <br /> any and all results and environmental assessment information to SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENo�n i ilable" t he same time it is <br /> provided to me or my representative. � ��Y �1�It <br /> PLEASE PRINT <br /> APPLICANT NAMES y�(�_ !� SIGNATURE <br /> TITLE <br /> (PHOTOCOPY RE RED) <br /> Approved ray Date g5 Accounting Office Processing Completed By " <br /> m�. Date f B_ � <br />