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San Joaquin County Public Health;Services Environmental I ealth.,Divlsior! <br /> GREEN FORM <br /> DATE I I ,[ MAS FILE RECORD INFORMATION <br /> SNADED 6RE69 FOR EHD usE ONLY OWNER Ip# I �����fT ' I CASE# � UNIT IV <br /> YYY "' OWNER FILE - <br /> COMPLETETHEFOLOW/NG PROPERTY OWNER INFORMATION.' CNECKIF OWNER CURRENTLrONFILEW/THEHD <br /> L <br /> PROPERTY J '^ �D Tyl -, PHONE <br /> OWNER NAME IVIFJ r�(�r�1 1F-rJ �elA <br /> Fvsl MI Iol Lf/ (,J <br /> BUSINESS NAME A ,I� 71`�5T- In,, �`, ,�,, Soc SEcITAx ID# <br /> Owner Home Address Ca.'7 �:�• (/� �O�C- fes' /��'� DRIVER'S LICENSE# <br /> City �C�1 vl•�Sp'-I STATE ZIP �.I Y'- <br /> Owner Meiling Address <br /> Mailing Address City ��• )C' -' rte, l Slate CIX ZipQI Jal5- <br /> CORPORATION❑ INDIVIDUAL PARTNERSHIP FED AGENCY❑ OTHER <br /> FACILITY FILE <br /> -FACILITY ID# 0'/ CRoss REF ID# ACCOUNT ID# a'. ci; MA <br /> COMPLETETHEFOLLOW/NG BUSINESS/FACILITY/ SITE INFORMATION: <br /> Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DIVISION? YES ❑ No ❑ <br /> Is this an EXISTING Business LOCATION but a NEw TYPE of regulated Business? YES f2 No ❑ <br /> BUSINESSIFACILITY/SITE NAME ^ ^O -r0 C � A A O f e7 I I <br /> SITEADDRESS ��� V"'�v r`r--G IV\ FL,vV SUITE# BUSINESS pMONE�2� <br /> CITY 7 Ll/L.II kJ STATE�rA _ ZI/P�I j/fJ�oJJ�B <br /> L.BOARD OF SUPERVISOR h. -. I,.LOCATIONCODE I .:...I KEYf ..I.:. _... .... .: .....��:..,,..ww�.z:,.,.[KEYZ(..�.. I�. :.._. . .. �_.:...II <br /> Mailing Address ifDIFFERENT/rom Facility Address Attention: or Care Of(optional) <br /> Mailing Address City STATE ZIP <br /> SIC CODE APN# COMMENT: <br /> THIRD PARTY BILLING INFO: Complete if Billing Party is different from Property Owner orFaclllty Operator Identified above. <br /> BUSINESS NAME Attention:orCare Of (optional) <br /> Melling Address PHONE <br /> CITY STATE ZIP <br /> AcoouNTADottEss for fees and charges OWNER FACILITY/BUSINESS THIRD PARTY BILLING <br /> III I.LIN ;AND CONPIJ AN(r.AeKNOWLEDGMl:NI'; I,the undersigned Applicant,cerlify that I am the Owner,Opernaor,or Ablhoricel.tgerr!orchis Rosiness,and I acknowledge(hal all <br /> PERMIT FEES,PENA/.TI6v,ENFORL'E:IIENT CIId ROEv and/or N0URI.1'Cl/.IR6ES associated with this operation will be billed to me at the address identified above as the Aca)LINI'ADOREII' <br /> for this site. 1 also certify that all information provided on this application is(rue and correct;and that all regulated activities will be performed in accordance will,all applicable SAN <br /> JOAQUIN COUNTY Ordinance Codes and/or Standards and STATE and/or FEI)k-",Laws and Regulations. As the undersigned owner,operator,or agent of the property located at the <br /> above facility/site address, 1 hereby notarize the release of any and all results and environmental assessment information to SAN JOAQUIN COUNTY ENVIRONMENTAL <br /> I I EsALTII DIVISION as soon as it is available and at the same time it is provided to me or my representative. <br /> --7— PLEASE PRINT _ p <br /> APPLICANT NAME �J ETF- �r ��'�{(� SIGNATOR <br /> A A ��� }}yyam� �j" -�-y � - <br /> TITLE MOF—r,�V Tp-0`r - J /2il)c��� DRIVER'S LICENS'FnA — <br /> ��l <br /> Approved By - Date Accounting Office Processing Completed 8 Date l'7 <br />