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Sa oaquin County Environmental Heal Department GREEN FORM <br /> DATE 3 2°f 0�; M TER FILE RECORD INFORMATION FR" <br /> / (I-,' <br /> � CASE# UNIT. IV <br /> OWNER ID# 11 CIO <br /> W( ., <br /> SHADED AREAS FOR EMD USE ONLY 7 <br /> OWNER FILE ' <br /> CHECKIF OWNER d61feENT6Y <br /> ONFREWITHEHD ❑ <br /> COMPLETE THE FOLLOWING PROPERTY OWNER INFORMATION,' /PHONE G•2� <br /> PROPERTY OWNER / 2�� <br /> NAME � �r G <br /> ✓C' k 7Z�T4 <br /> MI last <br /> First SOC SEC/TAX ID# <br /> BUSINESS NAME --�-�- <br /> DRIVER'S LICENSE# <br /> Owner Home Address 11791/ y CCG e S T-0 K Z�' <br /> S7ATt�y—t ZIP C s/�l <br /> city o"V <br /> Owner Mailing Address <br /> J State Zip <br /> Mailing Address City <br /> TYPE OF_ OWNERSHIP FED AGENCY El OTHER❑ <br /> CORPORATION❑ INDIVIDUAL PARTNERSHIP❑ <br /> FACILITY FILE <br /> CROSS REF ID# ACCOUNT IC # 7 � 2 INV# <br /> FACILITY ID# F <br /> COMPLETE THEFOLLOWING BUSINESS / FACILITY / SITE INFORMATION; YES No Y1 <br /> Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ No <br /> Is this an EXISTING Business LOCATION but a NEW TYPE of regulated Business? <br /> BUSINESS/FACILITY/SITE NAME �.i✓CG� - (l'CP .`��✓ <br /> SUITE# BUSINESS PHONE <br /> SITE ADDRESS Op isg 1 <br /> STATE <br /> Cm K <br /> I I I I <br /> BOARD OF SUPERVISOR DISTRICT I <br /> I LOCATION CODE KEYi Ker2 <br /> Attention:or Care Of(optional) <br /> Mailing Address if DIFFERENT from Facility Address <br /> STATE ZIP <br /> Mailing Address City <br /> SIC CODE <br /> APN# COMMENT <br /> THIRD�wftTY�,�I`asva I•-�o: r�,.r17 1pta if Billing Party is different from Property Owner or Facility Operator i entified above. <br /> Attention:or Care Of ("optional) <br /> BUSINESS NAME <br /> _ PHONE�� <br /> Mailing Address (f/Z 1pl('ll S <br /> ATE uP�2o <br /> CITY SCa L O <br /> dgagNTADD E-0 for fees and charges <br /> OWNER FACILITY/BUSINESS THIRD PARTY BILLING <br /> wledge <br /> FA <br /> BILLING AND COMPLIANCE ACKNOWLEDGMENT: I,the undersigned <br /> tC Applicant, <br /> dh this certify <br /> th w'ill�the billed to me atm the Owner, tthe/addre s identified above as theACCt UNT'ADor,or Authorized Agent of this Business, DRESS for this Site. l alslo cet f)'`t"l <br /> PENALTIES,ENFORCEMENTCHARGES and/or HOURI),CFLIR all be <br /> information provided on this application is true and correct; and th:ltndersi�ned owner,Solgatoities r,or agent of tile proluoty located tat the above facility sitble SAN e address,QUIN o herebyNTY the rcle:n <br /> Standards and STATE and/or FEDERAL Laws and Regulations. As thL u <br /> any and all results and environmental assessment information to SAN JO.AQUIN COUNTYEN\'IRONMENTAL HEALTH DEPARTMENT as soon as it is/:rya)ilable and at the same time <br /> provided to me or my representative. PLEASE PRINT 1 /J/' ✓ / / <br /> SIGNATURE <br /> APPLICANT NAME <br /> / DRIVER'S LICENSE# <br /> TITLE _ (PHOTOCOPY REQUIRED) <br /> �121/J e/ Date <br /> Approved By Date b Z <br /> Accounting Office Processing Completed By <br />