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San Jo--juin County Environmental Health D--)artment DATE IU MASTER ER FILE RECORD INFORMATION "IOR" GREEN FORM SHADED AREAS FOR EMD USE ONLY OWNER ID# CASE UNIT IV OWNER FILE COMPLETE THE FOLLOW/NG PROPERTY OWNER /NFORMAT/ON: CHECK OWNER CURRENTL Y ONFiLEwirH E H D ❑ PROPERTY OWNER NAME PHONE First MI Last BUSINESS NAME SOC SEC/TAX ID# Owner Home Address DRIVER'S LICENSE# City STATE ZIP Owner Mailing Address 2-2- 3 Mailing Address City 5 J / / State 2ip 9 S CORPORATION❑ INDIVIDUAL❑ PARTNERSHIP❑ FED AGENCY❑ OTHER❑ FACILITY FILE FACILITY ID# ]=:A CROSS REF ID# ACCOUNT ID# I1 INV# COMPLETETHE FOLLOWING BUSINESS/FACILITY/SITE INFORMATION: IS this a NEW BuSlnesS LOCATION not previously regulated by the ENVIRONMENTAL HEALTH YES ❑ NO ❑ Is this an EXISTING Business LOCATION but a NEW TYPE ofregulated Business? YES ❑ NO ❑ BUSINESS/FACILITY/SITE NAME SITE ADDRESS SUITE# BUSINESS PHONE CITY / / fir/ /� �"'fY STATE /i_) LP BOARD OF SUPERVISOR DISTRICT LOCATION FKY1 KEY2 Mailing Address ifD/FFERE/VTfrom Facility Address Attention:or Care Of(optional) Mailing Address City STATE ZIP SIC'.(MODE AP SIC # COMMENT: THIRD PARTY BILLING INFO: Complete if Billing Party is different from Property Owner orFacility Operator identified above. BUSINESS NAME Attention:or Care Of (optional) do VE ��SOcr l Mailing AddressPHONE 23a -70-7- ?3,2, -Z 6 CITY STATE(�/'n ZIP 5��7 1 7 AccouNTADOREss for fees and charges OWNER FACILITY/BUSINESS THIRD PARTY BILLING BILLING AND COMPLIANCE ACKNOWLEDGMENT: 1,the undersigned Applicant,certify that 1 am the Owner,Operator,or Authorized Agent of this Business,an PERMIT FEES, PENALT/Es,ENFORCEMENT CHARGES and/or HOURLY CH4RGE.S associated with this operation will be billed to me at the address identified above as the ACCOUNTADDRESs for this site. I also certify that all information provided on this application is true and correct;and that all regulated activities will be performed in accordance with all applicable SAN JOAQUIN COUNTY Ordinance Codes and/or 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 any and all results and environmental assessment information to SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. APPLICANT NAME PLEASE PRINT n�/fie SIGNATURE TITLE DRIVER'S LICENSE# (PHOTOCOPY REQUIRED) Approved By Date Accounting Office Processing Completed By '`�`I Date 29-002 April 25,2003 —44 Co