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• <br /> San Joaquin County Environmental Health Department <br /> DATE - GREEN;FORM <br /> MASTER FILE RECORD INFORMATION "MFRE �n i <br /> _a 1, a '�'_;..I._•, <br /> Sminrn■ usrngrwn,rccnN,v OWNER ID# <br /> S! SASE# Q i wJ N�T IV <br /> OWNER FILE <br /> COMPLETE THE FOLL OWING P RO P E RTY OWNER INFORMATION; tarFt 1�{WhfERy�iiRRFnrzraxrn�ivmr EHD <br /> PROPERTY OWNER NAME PHONE � .�,.�� ✓7 Q� n(1. // <br /> Frrst M! Last <br /> BUSINESS NAME <br /> /0A-- 40U/ <br /> � SOC SEC 1 TAX ID# <br /> Owner Home Address c6 XII-Al1 C�/" <br /> 1 DRIVER'S LICENSE# <br /> City Seo dv C STATE 'k zip <br /> Owner Mailing Address (J <br /> Mailing Address City State Zip <br /> T]tpE nr Awueeeure <br /> CORPORATION❑ INDIVIDUAL❑ PARTNERSHIP❑ FED AGENCY❑ OTHER❑ <br /> FACILITY FILE <br /> FACILITY ID# J E% CROSS REF ID# ACCOUNT ID# INV# <br /> Is this a NEW Business LOCATION not previously regulated by a NVIRONMENTAL HEALTH DEPARTMENT? YES I No ❑ <br /> Is this an EXISTING Business LOCATION but a NEW TYPE Of regulated Business? YES ❑ No ❑ <br /> BUSINESS/FACI RENAME Q. Gf o rar� <br /> SITE ADDRESS f/O ����A�� S /III�� _SUITE BUSINESS PHONE <br /> CITY 5/✓7O—zz 'TO u/11 <br /> /�9 �'J STATE zip ���a <br /> AR <br /> BOD OF SUPERVISOR DISTRICT LOCATION CODE KEYI C•�f KEYZ <br /> Mailing Address 1fD1FFEREMfrom FacIWAddress Attention:or Care Of(optkrml) <br /> Mailing Address City1%0 /i l „0/ e SrpTEA LP <br /> FC.):.E FP7N#�- 7T/ [Co.MFNT: C <br /> THIRD PARTY BILLING INFO: Comp/eteif Billing Party isdifferent from Property Owner or Facility Operator identyfiedabove. <br /> BUSINESS NAME /" Attention: Care Of (opiribMI) <br /> �I �Q <br /> Mailing Address /1, 'l!" }— `y il itle PHONE CID <br /> 13 <br /> CITYoddG�d7 G� ,! �1 prr�7J 7 <br /> TATE zip <br /> ILC^'•ur ^^��n for fees and Charges <br /> OWNER FACILITYIBUSINEES/S HIRD PARTY BILLING <br /> B[LLINf.ANTI f'DMPLIANCE A[KNOWI,I`UGMr' 1,the undersigned Applicant,certify that[am the Owner,Operator,or Authorized Agent of this Business,and L acknowledge that al!PIiRMIT PEES', <br /> PEMALTlEB,ENFORCEMENT CHARGEl4 andlor HOURLV CHARGES associated with this Operation will be billed tome at the address identified above as the ACCUlaTADDRE for this site, [also certify that <br /> 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 <br /> Standards and STATE and/or FEDERAL Laws and Regulations. As the undersigned owner,operator,or agent of the property located at the above fneilitylsile address,l 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 is available and at the some time it is <br /> provided to me or my representative. <br /> �QQPLEASE PRINT <br /> APPLICANT NAME l� �� <br /> 1'L2tvCf`S SIGNATURE <br /> TITLE DRIVER'S LICENSE# <br /> !i f. //D l O D (PHOTOCOPYREOUIRED) <br /> Approved BY Date Accounting Office Processing Completed BY Date I() I"C) <br /> 29-02-002 April 25,2003 �L <br />