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San Jo- --jin County Environmental Health D^nartment �... DATE c�!/�3 MASTER FILE RECORD INFORMATION "MFR" GREEN FORM SHADED AREAS FOR EHD_U_SE_ONLY OWNER ID# CASE# UNIT IV OWNER FILE COMPLETETHEFOLLOW/NG PROPERTY OWNER/NFORMATON. CHECK IF OWN _ERCURRENTLYON/FILE WITHEHD PROPERTY OWNER NAME PHONE First MI Last VVVVVVVV WWW I BUSINESS NAME ` � SOC SEC/TAx ID# Owner Home Address DRIVER'S LICENSE# city STATE ZIP Owner Mailing Address A51 1 SOV Mailing Address City J d( State q Zip 5 CORPORATION❑ INDIVIDUAL❑ PARTNERSHIP FED AGENCY❑ OTHER❑ FACILITY FILE FACILITY ID# CROSS REF ID# T ACCOUNT ID# INV# COMPLETE THE FOLLOW/NG B U S I N ESS/FAC I LITY/S ITE INFORMATION: Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ No [� Is this an EXISTING Business LOCATION but a NEW TYPE of regulated Business? YES ❑ No BUSINESS/FACILITY/SITE NAME �uf I` �\ 71 LA SITE ADDRESS So VO' l D 6(000(A 10 S SUITE# BUSINESS PHONE CITY G ll t11 STATE ZIP BOARD o,SUPERVISOR DISTRICT / LOCATION CODE IL KEY'I KEY2 Mailing Address if DIFFERENT from Facility Address Attention:or Care Of(optional) Mailing Address City STATE ZIP SIC CODE APN# COMMENT: THIRD PARTY BILLING INFO`: Complete if Billing Party is different from Property Owner or Facility Operator identified above. BUSINESS NAME C _ 1_ ro i' Attention:orCare Of (optional) Mailing Address 33 3 i V 1 D F i v PHONE Clrr / T STATE F^ Ivzip r%lyztG 4 CA �502, ACCOuNrADDREss for fees and charges OWNER FACILITY/BUSINESS THIRD PARTY BILLING BILLING AND COMPLIANCE ACKNOWLEDGMENT: 1,the undersigned Applicant,certify that I am the Owner,Operator,or Audeorized Agent of this Business,and I acknowledge that all PERMIT FEES, PENALT/FS,FNFORCFMFNT CHARGES and/or HOURLY CHARGFs associated with this operation will be billed to me at the address identified above as the ACCOUNTADDRFSs 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 JOAQUIryTY Ordina odes 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 ad ss hereby a Drize the release of any and all results and environmental assessment information to SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPART as soon as' i ailable a at the same time it is provided to me or my representative. APPLICANT NAME (-,own koWhn r, PLEASE PRINT SIGNATURE TITLE (, rrl y y 6V- DRIVER'S LIC SE# 1 UfJ ll {PHOTOCOPY QUIRED) J V Approved ByALL Date,S t Accounting Office Processing Completed By Date ?9-002 April 25,2003