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0 RgYME <br /> EcFi�F T <br /> iSan Joaquin County Environmental Health Department <br /> DATE p C GREEN FORM 2 <br /> 7 Z " MASTER FILE RECORD INFORMATION "MFR" 6/11V 06 <br /> 2066 <br /> A <br /> SHAnFrI ARFGS FAA EHr) ISF on, CASE OWNER ID# {� (�q[ UN <br /> � �j�'{'p�EIN QU/N CO <br /> V��,7i l IJ C i �T��PgFN7'q�NTY <br /> OWNER FILE FNT <br /> COMPLETETHEFOLLOWINGPROPERTY OWNER INFORMATION; 0iECHJF OWNER CURRENTLY0NF7LEwxTH EHD E <br /> PROPERTY OWNER NAME ^+y <br /> lr PHONE � YI / <br /> r First M1 Last <br /> BUSINESSNAME � .� SOC SEC/TAxID# <br /> Owner Home Address U DRIVER'S LICENSE# <br /> city STATE zip <br /> Owner Mailing Address D• ,I Hj_ <br /> Mailing Address City Zip 4� <br /> TYPF OF f1WNFRSHIR 1 <br /> CORPORATION❑ INDIVIDUAL❑ PARTNERSHIP❑ <br /> C FED AGENCY❑ OTHER <br /> �DrrN11�/� FACILITY FILE —r� <br /> FACILITY ID# �o4 E,yp,Q ..CROSS REF ID# C�) "'Nr ID# c��U INV# - Q <br /> OMPLETE THEFOLLOWING NFORMATION' <br /> Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT• YES ❑ No ❑ <br /> Is this an EMSTING Business LOCATION but a NEW TYPE of regulated Business? YES ❑ No ❑ <br /> BUSINFss/FAcnm/SITE NAME <br /> SITE ADDRESS /T �bf r f SUITE At /� BUSINESS PHONE <br /> Cm \ /y�R STATE/ A- ZIP <br /> BOARD OF SUPERVISOR DISTRICT LOCATION CODE KI:Yl FCI:Y2 <br /> Mailing Address ifDIFFERENTfrom FadlityAtYdress Attention:or Care Of(optional) <br /> Mailing Address City �j n y ` STATE ZIP <br /> SIC CODE APN# l 1 �L O L!f j (AMMENT: <br /> IL-THIRD PARTY BILLING INFO: Comp/ete/f BillingPartyIsd//ferentfrom Property Owner or Facility Operator/dentlfiedabove, <br /> BUSINESS NAME r Attention:orCare Of (optional) <br /> 1 �6 689frbri (cs Cos^ of- 2-s-o 332-515 <br /> Mailing Address P. 6. <br /> '{•�"Q- bo D-S PHONE^ <br /> CITY rri$V STATE 10A ZIP 716S <br /> ALC4:4A1mTAQ0RMF for fees and charges <br /> OWNER FACILITY/BUSINESS THIRD PARTY BILLING <br /> RI0.I.ING ANn CDMPt.tANCR ACKNOWLEDGMRNT: I,the undersigned Applicant,certify that I am the Owner,Operator,or Authorized Agent of this Business,and I acknowledge That all PENfrr FEES, <br /> PENALTIES,ENFORCEarzNFCRA,eces and/or ITOURLrCHARGES associated with this operation will be billed to me at the address identified above as the ACCOUMFADDRFcefor ibis site.I 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 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 DEPARTME T as soon as it' avails nd at the same time it is <br /> provided to me or my representative. <br /> APPLICANT NAME (J/C <br /> /�_JQ n L r6 5 r PLEASE PRINT SIGNATURE <br /> 7 t—1 <br /> TITLE DRIVER'S LICENSE# <br /> l �I S (PHOTOCOPY REQUIRED) <br /> Approved By Date Attountirtg O,I.-Processing Completed By -t- Date <br /> 29-02-002 April 25,2003 <br />