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! • <br /> San Joaquin County Er •ironmental Health Department <br /> DATE �v GREEHFORM <br /> MASTER FILE NV* )'�L' IV.FORMATION TTMFR" <br /> aPHn ert,r, i - - -- ---- --- UNIT IV <br /> I <br /> OWNER FILE <br /> COMPLETE THEFOLLOWING PROPERTY OWNER IwRmwyom CHEOVIF OWNER CURR£NTLYONFRE W"N END <br /> PROPERT"YOWNERNAME <br /> PHONE <br /> First MI Last <br /> BUSINESS NAME <br /> SOC SEC/TAX ID# <br /> Owner Home Address 9 <br /> c� RIVE0.'S LICENSE# <br /> City _� STATY X5 3 <br /> Owner Mailing Address <br /> Mailing Address City , <br /> State Zip ' <br /> TVCC rac nwNC04na <br /> CORPORATION❑ INDIVIDUAL E] PARTNEfI511m❑ FED AGENCY❑ OTHER <br /> FACILITY FILE <br /> FAa ID# CROSS REF ID# ACCOUNT ID# - INV# <br /> r <br /> COMPIM <br /> THEFOLIONTACE BUSINESS I FACILITY I SITE ZyEQRmA77oly.' <br /> Is this a NEw Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ No ❑ <br /> IS this an OUSTING Business LOCATION but a NEw TYPE of regulated Business? YES ❑ No ❑ <br /> BUSBNESS/FACILRY/SITE NAME <br /> SITEADDRESSSURE# BUSINESS Pf-IONE <br /> CITY Sr TE Zip 'qs33� <br /> Mailing Address ifDIFFERENTfram FaciifyAddress Attention:or Care of(option/) <br /> Mailing Address City <br /> STATE ZIp <br /> r <br /> THIRD PARTY BILLING INFO: Complete if Billing Party is diffe/entfrom Property Owner or Facility Operator identified above. <br /> Btssrh sS NAME e-ThL .56 u rc-e.. 6ro <br /> Attention:scare Of (options/J <br /> Mailing Address <br /> ,3V51—C C' �V// --7 C PHONE <br /> Cm <br /> (�� 1 <br /> STATE 2m <br /> for fees and charges OWNER FACILITY/BUSINESS V TrTHIRD PARTY BILLING <br /> Hlla]RC ANn fnniv uvrF CKNOW rnnrrnT; 1,the undersigned Applicant,certify that I am the Onner,Operator,or Authorized Agent of this Business,and I acknowledge that all PERAOTFEES, <br /> PEVALBFS,EA'FORC£N£Nr CHARGES and/or HOURLY CHARGES associated with this operation will be billed to me at the address identified above as the AcLOuyrd anRFec for this site. I also certify that <br /> all information provided an this application is true and correct;and that all regulated activities will be performed in accordance with all applicable SAN JOAQMN COMTY Ordinance Codes and/or <br /> Standards and STATE and/or FEDERAL Laws and Regulations. As the undersigned owner,operator,or agent ofthe property located at the above facility/site address,I hereby authorize the release of <br /> any and all results and presenn Live. assessment information m SAN 4Z PRINT <br /> N COUNTY ENVIRONMENTAL[ ARTAtEN it is available and at the same time it is <br /> �roany and <br /> all <br /> me or my d cnvieanmen. 61u_ E <br /> APPLICANT NAME PLEASE PRDYT <br /> SIGNATURE <br /> TITLE <br /> DRIVERS LICENSE# <br /> fPIgTOWPY REQUIRED) <br /> Appraved By Date Acmuntirg Office Protecting ComPlehA BY Date <br /> 29-02-002 April 25,2003 <br />