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San . �► r lm CO�inty x <br /> �; t 4,� i ,•� i 'd tr � r <br /> DATE <br /> 5- - a3 MASTER FILE RECORD INFORMATION <br /> GREEN FORM <br /> S"i <br /> — OWNER Io# UNIT IV <br /> OWNER FILE <br /> COMPLETETHEFOLLOWINGPROPER TY OWNER INFORMATION; CHECKIF OWNER CURRENTLYONFILEWITHEFID <br /> PROPERTY OWNER <br /> NAME PHONE <br /> First MI last <br /> BUSINESS NAME i <br /> Zto q SOC SEC/TAX ID# <br /> � C.tJ7Q <br /> Owner Home Address (o <br /> 3 DRIVER'S LICENSE# <br /> city O <br /> STATE <br /> Owner Mailing Address <br /> Mailing Address City <br /> State Zip <br /> T w ni:nwm a-z"TD 11�� <br /> r eniDnow"nN TNrinrtnl lel IJ Dt,DTTIFp•WTD❑ <br /> FFn Arrmry-EACII 17 El <br /> ❑ nTTdFD❑ <br /> f '' <br /> >Nva 7 M <br /> Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL.HEALTH DEPARTMENT? <br /> YES ❑ No <br /> Is this an EXISTING Business LOCATION but a NEW TYPE of regulated Business? <br /> YES ❑ No <br /> BUSINESS/FACIL rry/SITE NAME <br /> SITE ADDRESS <br /> /39 <br /> "jj �� Q�y SUITE# BUSINESS PHONE <br /> J O 11 <br /> CITY STATE ZIP <br /> Mailing Address ifDIFFERENTfiom FacilityAddress v Attention:or Care Of(optional) <br /> Mailing Address City <br /> STATE "P <br /> A� <br /> i.Lrl/'6�C <br /> THIRD PARTY BILLING INFO: Complete if Billing Party is different from Property Owner or Facility Operator identiFed above. <br /> BUSINESS NAME <br /> Attention:or Care Of (optional) <br /> Mailing Address PHONE <br /> CITY STATE ZIP <br /> LCOLUITADDRESS for fees and chargesOWNER � <br /> FACILITY/BUSINESS THIRD PARTY BILLINQ, <br /> ElLi.mr._ANn CUMEl LANCE ACI:NO.W EDGAIENT: 1,the undersigned Applicant,certify that I am the Owner,Operator,or Authorized Agent of this Business,and I acknowledge that all PERMIT FEES, <br /> PENALTTES,ENFORCEMENT CHARGES and/or HOURLYCIL4RCES associated with this operation will be billed to me at the address identified above as the ACCOUNT ADnRFQC for this site. I also certify that all <br /> 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,I 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 same time it is <br /> provided to me or my representative. <br /> PLEASE PRINT <br /> APPLICANT NAME ,�—r�~�. ^�-- SIGNATURE <br /> TITLE X b DRIVER'S LIE# <br /> K` (PHOTOCOPYREOUIRED) S �jL <br /> .ro>r By <br /> Date Accounting Office Proaessing'COmpleted B <br />