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San Joaquin County Environmental Health Department <br /> DATE <br /> � � Iti�`am7 MASTER FILE RECORD INFORMATION "MFR" GREEN FORM <br /> <uan�n eooec cno Eun vc�nx,v OWNER ID# `Sas- CASE# UNIT IV <br /> OWNER FILE <br /> COMPLETE TNEEOLLOWINGP ERWNER INFORMATION; CN£arFF OWNER CURR£NTLYMIUEE IYlnf END <br /> PROPERTYOWNERNAME G PHONE gas Op(7� SSS <br /> First M/ V 85( <br /> BUSINESS NAME SOC SEC/Tax ID# <br /> G <br /> Owner Home Address DRIVER'-L[CD+sE# <br /> C� An <br /> City Q STATE A <br /> 'op 9 Y 58'3 <br /> Owner Mailing Address <br /> D <br /> Mailing Addre7s City State 7Jp <br /> Tvoo,.c nw <br /> EDRPORATION INDIVIDUAL❑ PARTNERS!®❑ FEo AGENCY❑ OTHER❑ <br /> FACILITY FILE <br /> FAC6[Iy'I1)# � � CROSS REF ID# ACCOUNT ID# y7 / INV# I <br /> COMPLE7F 77YEFOILORWO <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? YES ❑ No <br /> Btt5DM/FACa[tt/SITENAMEG ` <br /> V SellO <br /> SITEADDflES5 0� �'� SUITE# BUSINESS PHONE <br /> —� <br /> Cm F AC mi r (�. STA ZID S <br /> BOARD of SUPERVi9tXt DtSTaicr 1�0 kf LOCtnoN CODE Q KEPI KU2 <br /> Mailing Address il01FFERENTfmmA3d1ityAddress t Attention:or Care Of(optional) <br /> Som¢ s <br /> Mailing Address City STATE Zip <br /> SIC CODE APN# 01 a. 1 Q S COMMENT: <br /> THIRD PARTY BILLING INFO: Comp/eete if Billing Party is different from Property Owner or Facility Operator identified above. <br /> BUSINESS NAME Attention:orCare Of (optional) <br /> TQYCa aC4 Gcosi? <br /> Mailing Address PHONE <br /> 1q9� rI o 9i2S ats...—p <br /> CITY STAGY'( � ?YJ /4 <br /> for fees and charges OWNER FACILITY/BUSINESS THIRD PARTY BILLING <br /> 1,the undersigned Applicant,certify that 1 am the Oamer,Operator,or Authorized Agent of this Business,and I acknowledge that all P£RVIrrM, <br /> PEVALHES,ENFORCEUENTCHA�,atu d/or HDORLYC)ZOtGESassmdsted with this operation will be billed tome at the address identified above as the ACM1AVrAOII»ace for this site. 1 also certify that <br /> all information provided on this application is true and correct;and that all regulated activities will be performed in accordance with all applicable SAN JOAQWN COt Ordinance Codes end/or <br /> Standards and STATE andiar FEDERAL Laws and Regulations. As the undersigned owner,operator,or agent of the properly located at the above facilitylsite address,l hereby authorise the release of <br /> any and all results and environmental assessment information to SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENTas mon as It' avail@ble and al the same time it Is <br /> provided to me or my representative. Y/c/•J•4rsQV rA'r'/s/!,1— <br /> APPLICANT NAME (� PLEAS�E PRII•1, SIGNATURE <br /> TITLE p DRIVER'S LICENSE# <br /> (PHOTOCOPY REWIRED) <br /> Approved By Date (7 Accounting Office Processing Completed By Date <br /> 29-02-002 April 25.2003 <br />