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San Joaquin County Environmental Health Department <br /> DATEGREEN FORM <br /> MASTER FILE RECORD INFORMATION "MFR" <br /> aMAD EDARFAa FOR EHD UK ONLY OWHERID# CASE# UNIT IV <br /> OWNER FILE <br /> COMPLETE TNEFOLLOWING PROPERTY OWN ER/NFORMAT/Ow CHEcK/F OWNER cuaxxEyour i.Ewni EHD <br /> PROPERrYOWNFA NANE g, � I'L. KAIF`J PHONE 9zs-514-38Z6 <br /> First M! Last �1 h <br /> BUsINges NMIE POC�l-T C. 0p "on SOCSEC/TxeH3# C5 /SSZVZ <br /> Snc. <br /> GWRarHorlleAddrBae G'75 Har43, keY RrvEp's LlcexsE# <br /> IAC. <br /> citySTATE C A zip 9y 5;Z fp <br /> D6nviUe <br /> OmerMtllinBAddmm <br /> (-Sep. Alcove <br /> Malling Address City See N.d ve stats ZIP <br /> DOIIPORAPON Ixomsuu.❑ PAHINFA9HIP❑ Fm AQEHarD OTHER❑ <br /> �U FACILITY FILE <br /> FPCILT'ID# M Glen REF ID# Accouw ID# INV# <br /> COMPLETETHEFOLLOWING BUSINESS I FACILITY/SITE INFoRMAnom <br /> IS this a NEW Buslneas LOCATION not proVIOUSly regulated by the ENVIRONMENTAL HEALTH DEPT,? Yes ❑ No L7 <br /> Is this an EwSTlNG Business LOCATION buts NEW TYPE of regulated Business? Yes I] No (� <br /> BU91NF99/PACILfF(/$frE NPMEC4w�-�-+rd L'emmvYTi� Qwrk <br /> $II£ADOp6a <br /> $UR # BU91HEa9PHONE1740SpieT`A` <br /> roe <br /> $TATE C.N1 Zip gs33o <br /> BOARDDFSUPEmn00R OKTpICT LADAnONCom KEYL KEY2 �- <br /> L <br /> NOlFFEAFMhsunFeGlllyAddras5 q I AtLandon:pr Care of(opUgm/Ja `a{�a390 '�O WhC Cee 4-,f Orivf- <br /> Clty `s STATECp 21P 95330 <br /> APN# CQNNva: l.YrBILLIN/G�INFO! Complete if8i11 ing Party is different from Property Owner OrFacillty Operator identifiedabove. <br /> / •i o Attention:orCam Of fopHonal) <br /> Mulling Address V PHONE <br /> CRY STATE ZIP <br /> AcnaLtilTAwams for fees and charges OWNER FACILITY/BUSINESS THIRD PARTY BILLING <br /> Bsu.wn Ane COAIFLIA CE ACKNOWLP.DensENT; L the undersireON Applicant,certify that I am the Owner,One 'a' <br /> or Audmnsd dgnR f Ihis Business,and I achnmvledge that afl Pearn Fein, <br /> PemAtnw,E.vm Cer[aTGuRGFSand/or AOURLTOURsetsssOClat<d with this Operation Will bebined lomeattheoddr e m thedttauMdaDRetr for this site Ialso certify that <br /> all Information provided on this appllmtion is true and correct;and that all regulated activities Will be performed In aceordmco With all appdeablc SAN JOAQUIN Comm Ordinance Codec and/or <br /> Standards and STATEand/or FemE Lona and Regulatiuss. As We undersigned owner,operator,Or agent of the property located at theabme hellity/siteaddress,I hereby ambariu the rcfeasr of <br /> any and all resin.and environmental msmament Informadan m SAN JOAQUIN COUNTY EWIRONMCNrAL HEALTH DEPA M m soo tl is available and at Ibc sane:time is is <br /> provided to me ormyrnpmentad.c �s �A <br /> APPLICANTNAME �i1✓�L-G NWE�S PLE05EPRINT SIGNATURE � <br /> T771-5 VP X L4kjJ0 MvT-W9MG1JTT DRIVER'S LICENSE# C5.75rf-Z <br /> (PHOTOCOPY REQUIRED) <br /> jiApproved By DpfA AccvwenO Dlflce Prpceatlnp CosnpiM^day DMn <br /> 1 <br />