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San Jpat 'i County Environmental Health D(' Ament DATE GREEN FORM MASTER FILE RECORD INFORMATION "M X4 ............ ............. SHAbED AREAS FOR ............... .......... ........... . . .................... ......... .............. ...... .... ........ ............. HO USE QNL UNIT IV ---------------... ...... ......... ........... ...... .............. .......... .. .............. .......... ................... OWNER FILE ,omPtE7'ErHEFoLLowAAG PROPERTY OWNER INFoRmwwm, CmEcKiF OWNER 0vRREynyomRLEwnN EHD -s-aLvil 6covy 4 H4 i>e F-ry PROPERTY OWNER NAME PHONE Prst M1 Last BUSINESS NAME .06 1-4.,Ila 4- SocSEc1TAxIDX N4 Owner Home Address )'13,5, r- %/-c In v-c- DRIvERsUGENSE11 A/4 city /-I t%n )'D PA /It STATE 64 zip 5 Y617 Owner Mailing Address VV-41 Mailing Address City S 4 V--4- state - ZJP TYPE QF O-Amr-01�"'P CORPORATION❑ INDIVIDUALD PARTNERSHIP l� FED AGENCY❑ OTHER❑ FACILITY FILE ......... ............................... ............. .................. 6WO ............. ------....... ...... .......... .............: .- . a I ---- ------- ............. ....................... ,�om PLErETHEFoLwww BUSINESS I FACILITY/SITE AfFoRmwww Is this a NEW Business Lorwnoi,4 not previously regulated by the ENVIRONMENTAL HEALTH DEPT.? YES 0 NO'%, Is this an FJOSTING Bushels LOCATION but a New TYPE of regulated Business? YES Q No Ig OwniEss[FACLiTyrorm NAME srrEftoRm 5, A-v ode) SurTE# BUSINESS PHFd"'-7-;?3 CITY -TV-ok (Z I STATE (A ZP 1 ............ ............. -- ---- ---------------- .................... VIS4R LocA DlsT .................... ----------------- -.......................... - --- -- ---------------------- ................ ............... ---------------------- ---------- ............... ...................... ........ Malting Address 19#-D1FFMZyrfiw"FaeftAdd"),Vx <t,)I m" Attention:or Care Of(ophomo 1 4 Mailing Address City UeA 4 4 V)� STATE(d ZP Isles 8 -------------------------............ ............ ............... ..................... ---------------- . _:z_.....__€......................... ............... ............... --------------- ---------- .......... ...... .......... nmilRDPARTY BiLLiNalwo: Complete hrBilling Party is different from Property Owner or Facility Operator identified above. Bt.mms NAME Attention:orCare Of(optional) 44 P�5 7 MaillingAddress NONE 70 7^-/ '// CITY U& STATE (4 ZIP AtwwmrAwam for fees and charges OWNER FACILITY/BUSINESS THIRD PARTY BILUNG :ILLINGAND COMPLIANcFACKNOwLEDGmYNT: L the undersigned Applicant,certify that I am the Owner,Operator,orAulhorWAgent of this Business,and I acknowledge that all PT-AwTFEES, tMaVESi EVF0RC;EvE;WCHARM andlorHouRLr CWARGEs associated with this operation will be billed tome at the address identified above as the ACCOUNTADORESS for this site. I also certify that R information provided an this application is true and correct-,and that all regulated activities will be performed in accordance with all applicable SA,'(JOAQU N, CouN-ry Ordinance Codes and/or tandards 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 releascof ny and all results and environmental assessment information to SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTWINT s so as it is available and at the same time itis revided to me or my representative. APPLICANT NAME PLEMS PMNT SIGNATURE " TITLE DRIVER'S LICE SE (PHOTOCOPY REQUIRED