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06/02/08 MON 14:42 FAX 9252999303 SECOR SF f7j002 <br /> San Joaquin County Environmental Health Department <br /> DATE 5 ! q C8 MASTER FILE RECORD INFORMATION "MFR" GREEN FORM <br /> SHADED AREAS FOR EHD US_E_ONLy OWNER IO# �}b'I�-�' CASE# U NI �IV� <br /> 111 OWNER FILE <br /> COMPLETETHEFotww l;PROPERTY OWNER INFORMA7'lo : CHECK/F OWNER CURRENTLYONFILE wrH EHLl <br /> PROPERTY OWNER NAME III;� - f�-r{_+ -- _ PHONE -4 1.� jj"9 <br /> /] n first Mt ��'"' � � Last •J <br /> 6U61NE66 NAME Peel-r!C Gas an / l f_c4 rtc sec SEG1T,>x ID# <br /> Owner Home Address Qu I,IE'SlSJ1 AJdCe(, - fs_ee- {jPjpL.LD DRIVER'sLICENSE# <br /> city I J l C s;17[u d d ress- See be l oW STATE 71P <br /> Owner Mailing Address <br /> Mailing Address City San c I S c 0 state C R [ZIP CI 4105 1 <br /> CORPORATION INDIVIDUAL❑ PARTNERSHIP❑ FED AGENCY❑ OTHER❑ <br /> FACILITY FILE <br /> FACILITY ID# g c._�7, I -.� CROSS REF ID# ACCOUNT ID M 33 R-3 q INV# 6 I ]I <br /> N: ` 1 <br /> COMPLETETHEFOLLOwtNG BUSINESS I FACILITY I SITE INFORMATIO <br /> IS this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPT.? YES ❑ NO lJy <br /> Is this an E%iSTING Business LOCATION but a NEW TYPE Of regulated Business? YES ❑ NO <br /> BUSINESB/FACiuTY!$iTE NAME VCL_G a r)+ 1 b_/ <br /> SITE ADDRESS _4'a Sc) SSo,C cva_tlhe n+O S rL-e4 SUITE# _ BUSINESS PHONE <br /> K- <br /> CRY 1 STATE C/,/N ZIP Cl 5,4-4 <br /> ,44 O <br /> =8.-. <br /> PERVI80R DISTRICT fiL,l LOCATION CODE it Z! KEY17- KEY2 ` <br /> (J <br /> Mailing Address 1fD1FFERENTfromFac/11tyAddress Attention:or Care Of(optional) <br /> I <br /> Mailing Address City STATE LP <br /> I <br /> SIC CODE FAPN# 4 S3 y o p �II COMMENT: <br /> THIRD PARTY BILLING INFO: Complete ifBilling Party is different from Property Owner or Facility Operator identified above. <br /> BUfiINE89 NAME Attention:orCare Of(optlorNtlJ <br /> SECoQ �n�erna+tenni, �n c. ho+� }�nFec E 0. i-ley <br /> [Mailing Address G-r L n{p y Q-k} a C i r c-te 2"d F'(o o r PHONE q 45- aqq, g 3 0 0 <br /> CITY L O,•FC,Ly -0 e— STATE C 4 ZIP 94V15 4 9 <br /> A.Q=VATAGGliesB for fees and charges OWNER FACILITY/BUSINESS THIRD PARTY BILLING <br /> BILLING AND CONIPLIANCE ACKNOWLEDGMENT: 1,the undersigned Applicant,certify that I am the Owner,operator,or Authorized Agent of this Business,and I acknowledge that all PERMTT FEF-S, <br /> PFNALTTES,ENFORCEMEATCHARGFs and/or HOURLYCHARGES associated with this operation will be billed to me at the address identified above as the ACCOONTADDRFSS for this she- I also certify that <br /> all information provided on this application is true and correct;and that all regulated acth•ltles will be performed In accordance with all applicable SAN JOAQUIN Coumy Ordinance Codes and/or <br /> Standards and STATE and/or FEDERAL Laws and Regulations. As the undersigned owner,operator,or agent of the property located at the above facility/site address,I bereby authorize the release of <br /> any evil all results and environmental assessment information to SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It Is available and at the same time It Is <br /> provided to rue or my represen[alive, <br /> APPLICANT NAME '1 Q M Il C h e a�PLEASF PRINT SIGNATURE C$)(P_QjjL� <br /> TITLE Pro L9C� SCien4lxt DRIVER'S LICENSE# 4 ��� <br /> I _LHOTOCOPY_REQUIRED) 1 <br /> Approved By Date - �u�'4 _JFAccounting Office Processing Completed By �� _ Date <br /> 29-02 10/12/07 MASTER FILE RECORD-GREEN <br />