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San - �quin County Environmental Healt lepartment <br /> 1-2-1�/- O MA ER FILE RECORD INFORMATION ` MFR" GREEN FORM <br /> OWNERID# � ;�o CASE UNIT IV <br /> OWNER FILE <br /> COMPLETE THE FOLLOWING PROPERTY OWNER INFORMATION: CHECKIF OWNER CURRENnYONFnEwrrHEHD <br /> PROPERTY OWNER PHONE <br /> // _ 0-T-31 J7l <br /> NAME "-'j ' G - <br /> First MI last <br /> BUSINESS NAME ) SOC SEC/TAX ID# <br /> Owner Home Address DRIVER'S LICENSE# <br /> city I y (,/f �ch <br /> uP <br /> Owner Mailing Address <br /> Mailing Address City State Zip <br /> cr.n.. .f <br /> TYCF nF nwwgsw <br /> r�llO DING/ITTIIN TNATRhIIAI I I DIIDTMFO euro I I FFA An-I I (�T4lFO I I <br /> FAr-11 1XX Fill 1= <br /> FAat.m ID# r�' CROs REF ID# - �r <br /> AccounTID# INV#�..�(.1.:� �f <br /> PLETE THEFOLLOWING <br /> Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ No ❑ <br /> Is this an EXISTING Business LOCATION but a NEW TYPE of regulated Business 7 YES ❑ No ❑ <br /> BUSINESS/FACILITY/SITE NAME <br /> SITE ADDRESS SUITE# BUSINESS PHONE <br /> G-1 vc Ud�(.J —c� /ju c <br /> CITY STATE ZIP <br /> Al <br /> IIBOARD OF SUPERVISOR DISTRICTI I LOcATION CODE I -- I KEYl I _. ,. .., ..,r SF... IKEY2 <br /> Mailing Address ifDIFFERENTfrom Facility Address Attention:or Care Of(optional) <br /> Mailing Address City STATE ZIP <br /> SIC CODE APN# t{(D 3 V{ U COMMEHC <br /> -THIRD PARTY BILLING INFO: Complete if Billing Party is differentfrom Property Owner orFacility Operator identified above. <br /> BUSINESS NAME i G Attention:or Care Of (option/) <br /> •- 1 � L_ C <br /> V (7f MGN r'M<, `'IC'l <br /> Mailing Address /9 c� PHONE <br /> �► c� l.J. l � /�oc.�Y mac.: - `� 3i- 3�ic <br /> CITY STATE Zip <br /> S�-c L <br /> ACWuAtTAnnnFcc for fees and charges OWNER FACILITY/ROSINESS THIRD PARTY BILLING <br /> BILLING AND COnIPI IAN(E ACSN'OwI.FDC.njFNT: 1,the undersigned Applicant,certify that I am the Onwer,Operator,or Authorized Agent of(his Business,and 1 acknowledge that all PF.RAtir FEF-c, <br /> PF,NALTIEs,ENEORCFAIENTCHaRGES and/or 1101IRLFCHARGES associated with this operation will be billed tome at the address identified above as the ACCOrWTADORFCC for this site. 1 also certifv 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 JOAQl1TN COUNTv Ordinance Coles and/or <br /> Standards and STATE and/or IFF.DFRAL Laws and Regulations. As the undersigned owner,operator,or agent of(he property located at the above facility/site address,1 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 SIGNATURE <br /> OL, <br /> TITLE DRIVER'S LIG S # <br /> (PHOTOCOPY REOUIRED) <br /> Approved By Date t Accounting Office Processing Completed By ` ( C <br /> :sL.-. Date <br /> iy <br />