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San Joaquin County Environmental Health Department <br /> IGREEN FORM <br /> DATE g/Z�I��` ` MASTER FILE RECORD INFORMATION "MFR" <br /> .•zone .n„z ,v OYdned IDS. / G�sE'XF' <br /> UNIT IV <br /> OWNER FILE I I ' <br /> t?fCCKw OWNER C2/RACNnyojv x=W77N EHD <br /> COMPLETE THE FOl1OWING O OWNS INFORMATION: <br /> PPQ91;n„TYOWNERNAMC V✓I�r J �v /,Z,- Pt+OrvE <br /> Las <br /> f�� ! First (� PAI .* <br /> HU + NAKE �(f Sx SEC/TAX ID# <br /> Owner home Add rDRivfR'SLSffxSE# <br /> fi . p <br /> City 1 `O C� STATE G A- z11P <br /> owner Mairing Address <br /> Mailing Address City State Zip <br /> i <br /> (pnrorsATltx+ IAtl7IVA3UA1 PARrnGRSM1p❑ Fm AGENCY 0 OTHER l] <br /> FACILITY FILE <br /> i FACLrrY ID 4F 0 CRoss REFID# ACt ouNT ID# INV# <br /> a <br /> Is this a NEw Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT- Yes 0 No <br /> Is this an EX=NG Business LOCATION but n NEW TYPE of regulated Business? Yrs 0 No <br /> atj- yw ss/FAcim/SM NAME r <br /> l./ (l{ E 1 L"G._. SLJITL BUSII1 Pt <br /> S=ADmcss - <br /> ` Za - s Z <br /> cm <br /> '71ATI CtkZIP ` 52�t <br /> BOARD 0F$l1PRRVZ0RDMR= LOL`ATIDN CD DE I KEYS xCYZ <br /> Mailing Address ifDIFFEREWfiDrnFadlityAddrsss Atberrtlon;or Care Of(OpdOnJI) <br /> Mailing Address City S-rA- Z- <br /> SICCODe APN# I l3P-0 O 0s �MMErfP D O �a <br /> THIRD PAIeTT BILLING INFO; Complete if Billing Party is different from property Owner orFacilityOperator idenbfiedabove. <br /> SUSIII LSS NAME Attartdon:arCare Of (OD60MI)�� <br /> Mailing Address Z5 25 IBCA-Tt� � Pc,r` �J r. l ��j� PMON! gl�O— !2 — /,=-7Q <br /> a'„ srATe C�. Z" `1S 8 33 <br /> AOR.RFiN for fees and charges OWNER FACILITY/BUSINESS HIRD PARTY BILIJNG <br /> Fin,rvr_,n Mvrot r,Nrr 1�'voytiT fiDatra}-r: I,the undersigned Applicant,ura(y than I am the Omer,Oprrator,orAuthori:edASg of of thin Business,and I acSmowledge that All Pa-WTFP.RS <br /> pF.vtr.nEa,z7vFORCFsi l)vv7CHARGFS andlor HOURLY CHARGES woaamd"th this operation will be billed tome at the iddrrs identified above a thcd=QLvIAD2s=lbr&b site. I also ccrdl( that <br /> Ill ialormurion provided on dui application b true and correct,and that all regalated aCtivitim will be performed is uccordance with all apphcablo SAY JOAQLTi COUYfy Ordinance Codes mtdlor <br /> -,tandards and STATe and/or FUMIAL Inws and RegUatiam.A-%the under-iE cd owoer,operator,or agent of she property located at the about CaaTltyfsitc addras I bercby authorize the rckwe or <br /> any and all rutdo and eavima cental aNWM-mt information to SAN JOAQM COI N'TY ENVIRO`��"-r1'1L HF LL'I'FI AFP#RT��T n a t;!available and at the same time sr is <br /> pro,ided Io me or rny rcprc3cutadvc. <br /> � P paurr — SIGNATURE <br /> APPLICANT NAME ���'�- <br /> -SLE DRIVER'S LICENSE# <br /> �I Approved By b71A Acmuttbr4 Ofiee pre jng CDmplctcd 6y CafL <br /> 29-0:-002 April 25,2003 � • <br /> Z 'd 69Z 'OU <br /> o1N3�V�'d��s Uur3 Wdtiz �� Booz '�z '��� <br />