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� to <br /> San Joaquin County Environmental Health Department <br /> OATS IO k oc? MASTER FILE RECORD INFORMATION `gMFR" GREEN FORM <br /> SHAOap ARFALQ EHO OtLLY OWNER ID# / UNIT IV <br /> I / CABE# <br /> OWNER FILE <br /> COMPLETE THEFOLLOW/NGPROPERTY OWNER/NFORMAT/ON.' CHemr/r OWNER CURRENRYONrnewnN EHD El <br /> PROPERIYOWNERNAME <br /> --- TF^1"F`CsrrS M G G . PHONE ZS 1 r- <br /> Firt AlLuatt <br /> BUSINESSNAME SOCSECITAMID# <br /> Owner Hame Address C) 0 WST IQ E DRIVER'SUCENSE# <br /> City STo oG EST <br /> 1 G STATE ZIP 9ST O <br /> O Owner MBHln#Address 3l O �o tCA/\/ <br /> ^�Y0/j P-0A t / L- <br /> ^ Melling Address City ` )l ()N 7�Y <br /> -1 J <br /> I CORPORATION INDIVIDUAL EJ PARTNERSHIP El FEOAOENCY❑ OTHER❑ <br /> v FACILITY FILE <br /> FACILIVID# I �� CROS;REF ID ACCOUNTID# rQ f INV# <br /> COMPLETE THEFOLLOW/NG BUSINESS/FACILITY It SITE/NFORMAT/OM. J o <br /> Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPT.? YES ❑ No ❑ <br /> IS this an EXISTING Business LOCATION but a NEW TYPE Of regulated Business? YES ❑ No I] <br /> BusWE;;IFACIU7WSRENAME G rY 5 <br /> SITEADDRES; /D0/1 O \ V/ t L^,1 r� SURE# ^ SU9191MEESSP`HTONE <br /> CITY 5-To <br /> C,` —r c�W�+ I Tl/V�i STATE C/+ <br /> +ZIP qSz a <br /> BOARD OF SUPE RVIEDR DISTRICT I V LOCATION CODE KEYt HEV2 to 1 <br /> M;IIIng Address KO/FFENENOTfrom Fac/l!(yA re�e•' OV 0/+ ANenion:ar Care Of(optlonal/ <br /> W L/TV KR <br /> Melling Address CRY SAN pd O A/ STATE// A— ZIP <br /> SIC CODE APN# COMMENT: LAI U vJ <br /> THIRD PARTY BILLING INFO: Complete ifBilling Party is different from Property Owner orFacllity Operator identiTedabove. <br /> BUSINESS NAME , •/ <br /> TA/�TE � ASLLL 6- �Q,O� C/V Atte gon:OrCareOfVA nes 1— <br /> Meiling Address 9 / n F^ � r n e GL� )-. ' D D n PHONE ZTS", zR 9. 930 o x Z,3 <br /> Cm `/1fA`(� /T C. V/l LJl /` STATE zip/Ilys q <br /> ACcoUNrAvcR forfees and charges OWNER FACILITY/BUSINESS THIRD PARTY BILLING / <br /> BILLING anD C.supLuxcE A 1,the undersigned Applicant,c¢rHfy that l em the Oeeaq 0peramY,or Aurhad dAgent of this Buslsess,and 1 acgnmvledge that all PRR.1/IrFBEs, <br /> PENALTIES,ENFORCAVEATCHARGES and/or HOURLY CHAROEY associated with this operation still be billed to me at the address blemished above as the A[CDONrACDRESS for this site. I also certify that <br /> as information provided on this application Is true and correct;and that oil regulated acdvitm will be performed In accordance with all applicable SAN JOAQUIN Cowry Ordinance Codes aatl/or <br /> Standards and STAYS anchor FEDERAL Laos and Regulations.As the undersigned mvneq Operator;or agent of the property located at the above facility/site address,I hereby authorize the release of <br /> any and all result and environmental assessment information to SAN JO•%QUIN COUNTY EN ONMENTAL FIEALTB DEPAKTMENT as soon as It ie end of thaymm e same time it Is <br /> provided to me or ety represamtt."gre. <br /> 11 b] <br /> APPLICANT NAME Ij UI, 9 PLEASEPRINT SIGNATURE 6t-,-Gk <br /> TITLE DRIVER'S LICENSE# <br /> Przosczr �A�vhrC,�12 <br /> .(PHOTOCOPY RE001RE0) <br /> Approved By Date ACDoun;n I Mae Praceaslna Completed BData Z <br /> 29-02 10/12/07 <br /> MAS'rlsR FELE RECORD-GREEN <br />