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San Joaquin County Environmental Healthartment <br /> DATE f / GREEN FORM <br /> 1/ /�/�'7 M�R FILE RECORD INFORMATION 11R" <br /> °MER 109 Lf CASE# UNIT IV <br /> OWNER FILE <br /> MPLETE7HBFOLL0111WrNCPROPERTY OWN R INFIORMATION,• 0"`A f OWNER cVmwnro#vnwwnN END <br /> PROPEM Owrien NmE jr-04,\/ LUNDQGtIST Perone <br /> 209- 334--3L <br /> First M/ Last <br /> 2estderlce <br /> /�(�j -y SOC SSC/TAX ID# a <br /> Owner Home Address1 -{ _!7 T N Zkw IS �p( DwveR'a LErarg# N/A <br /> city L—ooL i <br /> STATE CA m' 95z4z <br /> Owner Mailing Address S°e, nY — as --bow <br /> Malang Address enY <br /> 1 sate lip <br /> CORPORATION 11 INDIVIDUAL 17S! PAamEaswn❑ Fen AGescr❑ <br /> OrNEx❑ <br /> Q FACILITY FILE <br /> FAQISTYID# 0 6to55 ReFID# ACcounr ID# 31 INV# <br /> 15 this a NEW Business LOCATION not previously regulated by the ENvIRONMENTAL HEALTH DEPARTMENT? YES ❑ <br /> No ❑ <br /> TS this an EIGsnNG Business LOCATION but a NEW Type of regulated Business? <br /> YEs ❑ No ❑ <br /> Busmess/racuuTy/Sing NAME 1 <br /> SIIE ADpBEssCl <br /> ( I V ` 1J OL lJ t S sum# &mreESSPNOW <br /> CITY <br /> L°�- STAT `P <br /> BDARD oP sumvfsoa DESMa �}� Locotsm CODE Iq KEYL <br /> V lOy2 <br /> Mailing Addre�/fDIFFERFftM Fad/ityAtYdress <br /> Attention:Or Care Of(opliorw/) <br /> Mailing Address City <br /> SPAM j p <br /> SIC Coon APN# 0 13 O 7i <br /> Z CoMMEnr: <br /> THIRD PARTY BILLING INFO: CompleteY Billing Party is different from Property Owner or Facility operator identified aGoue. <br /> BUSINESS NAME �_OD_" <br /> PI1 i I S Ficvoi cl N1t d I�el �il�� S Care Of (eaf;a ail <br /> Mailing Address f f �tO0 �W 1, 1 rl f. li W (,Z <br /> �T V <br /> CM L- w istag C A rm 9s 2y z <br /> -"Q"`f®�=for fees and charges <br /> OWNER FACILITY/BUSINESS THIRD PARTY BILLING <br /> Bst s s C A : 1,the undersigned Appgcant,certify that I am the Owner,Operator,or ludrorized Agent of this Business,and I acknowledge that all P£Aanr E££s, <br /> P£NdGtr£8,ENFGAC£at£NrGTAAGEe and/or H0VRLyC tRG£s associated with this operation will be baled to me at the address Identified above as the AGWI T ADARESS for this sit, I also r,rdthat <br /> all Information provided on this application is true and correct;and that all regulated activities will be performed in accordance with an applicable SA JOAQM COUm Ordinance Codes and/or <br /> Standards Bud STATE and/or FEDERAL Laws and Regulations. As the undersigned owner,operator,or agent of the property located at the above faculty/site addma� I hereby authorize the release of <br /> any and all results and environmental assessment information to SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It "liable and at the same time it is <br /> provided to me or my representative. / <br /> APPLICANT'NAME <br /> /APV/'VI /N �i PIEA.sE PRmr SIGNATU <br /> TITLE 77 <br /> DRIVER'S LICENSE# <br /> (PHOTOCOPY aEouNeEDI <br /> Approved Y 8 /�L Dasa / //� a l <br /> 1 ' --Office _ irm Completed By <br /> 29-02-002 Ap 125 2003 <br />