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<br /> .San.
<br /> q 3 uin.Coun
<br /> . tyEnvironmentalHealtepartment}
<br /> DAT I GREEN FORM
<br /> l MASTER FILE RECORD INFORMATION "MFR"
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<br /> syf :OwNEItID' h _ .'`.�k Z -i i;5- e s •, �F,,> - • t a.:
<br /> ;4; . s. ►�; ' ' 4 {3csuE#i �, f ixt n y ,S UNIT IV
<br /> OWNER FILE
<br /> COMPLETE WEFioLLO&WNGPROPERTY OWNER INFORMA770N. _' � OECKAF OWNER Cfur►tEsnravFrcEwnr►EHD
<br /> PnovEatY OMER I a
<br /> { NAME PHONE
<br /> F*V UP
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<br /> $USIriE55 NAME * if
<br /> .h 12w , Guru roc sec/TAx ID#
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<br /> Owner Home Address
<br /> ORMER'S LICENSE#
<br /> city Z1P
<br /> Owner Ila"Address
<br /> Mailing Address Citi, l
<br /> z - Zip 95. 3 d
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<br /> rnaeno,ar�nwn - � �Truin..m -. _,,.. Yy }� r i.iH c'Hi{r' 'i [ (•1F.i 11 Yt',,.-[ :'F:-;: rl .
<br /> 1'7-'- 'AeeTM,eetyrel I 7 FcnA;;r I
<br /> FAC
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<br /> .>-FACILIiY -f-'- ..t"d .' l-��: . a .=G y,� `;�#l.:.w' YtY%E�?a
<br /> ID#. � ��• �G;s ReFID;#.'i1 CCouNTID
<br /> _ n}�x.� 1.-sl,a.. !'Y-h„' tl."�v�`•� ,F,i.t;a..�.�C�.wa?r;�:'
<br /> Is this a NEw Business LoanoN not previously regulated by the EMRONMErrrAL HEALTH DEPARTMENT) ” "' '•' 1 "'Y''
<br /> YES ❑ No ❑
<br /> IS this an ExIsrsNG Business LoCAT10N but a Niw rfk or regulated Business 7 >,-- - '•- --
<br /> ;� s .. 'YES ❑ No ❑
<br /> Business/F LITY/
<br /> SITE ADDRESS .. - ;'•` •-..
<br /> Sum/R. .."---$IISIPIE55 PHONE
<br /> (J 6 12
<br /> cm 'STATE ZIP
<br /> BDAFiD 1�T iItiY- �.7ttri. y ,u t,.1 .r.� --;' ;•"-c j -�5 h^c^*'Rr}--T. rT� �f' ?+. ,C � �
<br /> OF SUPERVISOR D>sTatCr:X--� q..-.t # LDGITIOl1 CODE I r6 ,f34.+ t�L,...ai, i .:t lz II ..v. aJ � . i �.:�e iY �3 ti:l'
<br /> - _a.o?..r�v..v� ua•.�t... wV,m hf?,wa/. .L �+r v-r:,v r �n . irY ] rN .r. +�ci�.f �� XMN � C
<br /> 3w1�i Nr. 'XE �47tt{n i:►ti se+.,nai ^�diY{5!..�'��f v3
<br /> Mailing Address ifDIFFEKENTfmm FaalltyAddmsc - - --..—.-__ _ '"
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<br /> Mailing Address City...
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<br /> ZIA
<br /> SIC. � �
<br /> .i. �s.�ewhcl-?�ti:' a �� �!'�!!,, �, �y ...��TI��1 �55i���,1i.h%t c}•ya fe�.�}'.i
<br /> H1RA PARTY BILLING INFa; Comp/eteif B'sllilTg Party is differentfit�m Property Owner or Facility Operator'idendrreda6el+e
<br />. �3ustnE55
<br /> ..� Attention:orCare Of (optional) I
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<br /> - _
<br /> Nailing Address ..PHONE
<br /> ..STATE -- ZIP _
<br /> for fees and charges OWNER FACIL17y/13USMESS �} 1. ' 'THIRD PARTY RiLLING
<br /> 'J,the undersigned Applicant,certify that i am the O»+ner,Oyeraror,or Aafhllon&44jrel of Ibis$urine
<br /> vA""S,F"'FORCEMENT CIIAJIGFT andler llotrgtYC►tAnGFT associated with this operation will be billed tome at the address Idendrted above as the Aetnw rwn� Kllnorrfnigc Ihat all PEgAnT FEFs,
<br /> R1L_far Ihls site. I also certify flim all
<br /> irmation provided an'his application is true and correct;amt shat all regulated activities will-be'pe`formed in aceordi�rce with all applieab[e SAN fo�Qel�ii Cbutrry Ordinance Caries andlar
<br /> Wards and STATE amVor l EDeRAL Laws amt Regulations, Aa the undersigned owner,opera'or,or agest of the proper'y�localtd at'{the above'facittlyhi'e address,1 herby authorise the release or
<br /> and all results and env[ronmealal asse'ssmeal information to SAN JOAQUIN COUNTY ENVIRQNMENTAL IIEALT
<br /> wided to me or my representative. iI, DEPAHT'MENT.a;-soon as-it Is available and at the same time it Is
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<br /> PLEASE PRINT
<br /> LICANT NAME SIGNA 11JRJ -
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<br /> .y(ITLE DRIVERI 5 LTCENSlE#
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<br /> •pPfnVedBY c<•+rr��,:aac�:?zti-c.�� -Da>ia'�,"x�+�k.5h_anY ���,�;::,� s ..� - ... ,. ti�y,,-� �� .. .
<br /> � �?`2`+'�es�.��-:. rAOCOUnt�nQ�Of$C{Pf'OOPSSif14.GDt!}pIC40d By.',-t?tdt`fns..ie+�;•� r"' :t- .Dat@` ��: � '.,,'Z, .._r' �,
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