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k 1t <br /> San Jo0in County Environmental Health Dortment <br /> DATE RECORD INFORMATION "MFRGREEN FORM <br /> Cu D MASTER FILE "MFR" <br /> GREEN <br /> AREAS FOR ENn nsF ONi Y OWNER ID# �j� 7�I1�1�G.� SASE# UNIT IV <br /> (J L(f�(N <br /> OWNER FILE <br /> COMPLETE THE FOLL 0WINGPROPERTY OWNER INFORMATION; CHECKIF OWNER CURRENTLroNFILEwr7H EHD <br /> PROPERTY OWNER NAME PHONE <br /> Forst M/ Last <br /> BUSINESS NAME TAC-IFIL I L '`AILROA� �O rA�A t4 SOC SEC//TAX ID# <br /> Owner Home AddressZC" <br /> �� DRIVER'S LICENSE# <br /> t 1/ Y <br /> city / <br /> C7S STATE ZIP <br /> Owner Mailing Address11 <br /> I LJ I I ►� r r /J ! <br /> *—rr�—rJo u ty L i(<( �tl b 7N/ I J r 1 0 <br /> Mailing Address City <br /> I -- State Zip <br /> TYPE(IF nwNFPSHTP <br /> CORPORATION INDIVIDUAL❑ PARTNERSHIP❑ FED AGENCY❑ OTHER❑ <br /> FACILITY FILE <br /> FACILITY ID# I / C I CROSS REF ID# :_:_:: ACCOUNT ID# "'1 -u) INV# <br /> MPLETE THEFOLLOWINGN• Oc <br /> IS this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ No ILy <br /> IS this an EXISTING Business LOCATION but a NEW TYPE Of regulated Business? YES ❑ No <br /> BUSINESS/FACILITY/SITE NAME S TV L X�V <br /> SITE ADDRESS <br /> 3 3 �A S- g 5 T Q.��'� SUITE# BUSINESS PHONE <br /> Cm s T J( IC'T J STATE C ra ZIP 9 5,Z 06 <br /> BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEY1 <br /> I Mai ng Address 'DIF ERENT Tom F ci tyAddress Attention:or Care Of(optional) <br /> Mailing Address City D V STATE 0 ZIP S tl� I 1 <br /> SIC CODE APN# COMMENT: /r'w T L 1 <br /> THIRD PART BI LING INFO: Completeif Billing Party isdifferent from Property Owner or Facility Operator identified above. <br /> BUSINESS ME Attention:orCare Of (optional) <br /> Mailing ddr.S1 PHONE <br /> CITY STATE zip <br /> >9AXDuN*4DDREse for fees and charges <br /> OWNER FACILITY/BUSINESS THIRD PARTY BILLING <br /> Rn t W;AND C'OAIPI IANt'F CKNQII YDCn 1F 11' 1,the undersigned Applicant,certify that 1 am the Owner,Operator,or Auth orized Agent of this Business,and 1 acknowledge that all PERmn'FEEs, <br /> PEn'.u.17 s,E:Vf0RCEn1F.NT(W tltOES and/or IlOURLYCIHARUES associated with this operation will be billed to me at the address identified above as the ACCOPNTADDRECC for this site. 1 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 facility/site address,1 hereby authorize the release of <br /> any+uuul all results and emironniental assessment information to SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available a at the same time it is <br /> provided to me or Illy representative. <br /> APPLICANT NAME ^� PLEASE PRINT <br /> —�6 f4 SIGNATURE <br /> TITLE <br /> �PLICENSE <br /> REOUR / <br /> O�y� <br /> Approved By Date Accounting Office Processing Completed By Date V 0 <br /> 19-02-002 :april>>.aoo., <br /> CONFIDENm <br />