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-r- t <br /> u• :s�a�•-c.,l •��•-w-� � ddtn� GREEN FDR <br /> N + 6700 MASTER FILE RECORD INFORMATION "MFR" <br /> HATE 7_ UNIT IV <br /> OWNER FILE <br /> OWNER INFORMATION.' CNECKIF OWNER CLRREN7LYONFJLEM777•IEWU <br /> CoMPLETEITHEMLLOW1,111--t"OPERTY / . PHONE <br />' PROPERT <br /> OWNER NAL L� ' <br /> M Jsa } <br /> F+s1 <br /> Sec SEC r TAX to# �� ! p <br />'I BUslNE5s NAME J • - <br /> I L r'r <br /> pRIVER'SLICENSE# <br /> / <br /> �j W � ar <br /> Owner Home Address G.7E 7vj <br /> STATE zip <br /> city �- r/ <br /> Owner Maaing Addre" 2 7� r <br /> f State Zip Gtr <br /> Mailing Address City <br /> FED AGENCY❑ OTHER❑ <br /> CORPORATION❑ 1NOIYIOUALK PARTNERSHIP❑ - <br /> FACILITY FILE <br /> .. ._ <br /> _ — - - u' xsce�aa:R4-Lex.- c_,«�� -�[-!'.���:.'=::n�•tljr: <br /> COMPLJE7E7-HEFoLLOWING BUSINESS/FACILITY/SITE INFORMA710N <br /> YES No ❑ <br /> Is this a NEW Business LOCATION not previously regulated by the EMviRONmewAI HEALTH OIVt31ON? <br /> YES No ❑ <br /> Is this an E 3snNG Business LOCATION but a NEW TYPE of regulated Suslness? <br /> L SuSI4Ess1FACtL+tY1SITE NAME <br /> 12 <br /> . LL] su}TEx BUSINESsPHONE <br /> SrTE ADDREss 3� <br /> 1 <br /> STATE zip <br /> CITY __ -` -. .�-�:—L:•y-i2 --w:._ <br /> I ._ -� <br /> t _ lea:-- _'. - . "• <br /> Maii'mg Address ifDIFFEl+IClilT frorrr FaaililyAddress <br /> Attention:or Care Of(0ptlonall <br /> S <br /> Mailing Address City <br /> 1 THIRD PARTY BILLING INFO: Complete if Billing Party is different Owner or Facility Operator iden�edabove. <br /> Attention.or Care Of (optiorralJ � <br />,r Bus+NESS NAME <br /> 4 f — <br /> PHONI <br />]. I Mailing Address — -Q !Ty � y2 <br /> S <br /> CITY `-STA ZIP C;)L �0'7 G C: <br /> a 1 <br /> Accourvr �EES� for fees and charges <br /> pyyN FACIilTYIBIJSINF THiFto PARTY BILLING <br />{ Juor.or Antkarfud Agenr of this Business,and 1 Acknowledge that 911 <br /> BILLING AND COMpUANCl.ACKNOWLEDGMENT: I,the undersigned Applicant:certify that!am the.owner-� <br /> PERMrr FEES.pU"L77EY..ENfURCEkfBl+rr CJt tRCeS asdlor FIuUF/.Y[JfARCES asaoeiated Wilk this oper'atiao will be bilk+d to me at the address identified above as the AgC)V NT AnnRES <br /> j <br /> for this site. 1 also certify that all information provided on this application is true and correct and that all regulated activities wiSA <br /> ll owner,t>er ormedor Basin accordance <br /> of,he property locatedwith all apikzb'at e <br /> 1 JOAQukN CouNTY Ordinance Codes and/or Standards and STATE and/or FEDERAL Laws and Regulations- As the undersi9►ed <br /> above facility/site address, t hereby authorize the release or any and all results and environmental assessment information to SAN JOAQUIN COUNW ENVIRONMENTAL <br /> HEALTH DIVISION as soon As it&available and at the same time it is provided to me or my rep.esattative. <br /> Pt.EAs P +Nr <br /> SIGNATU C-•� y'[-� G'� <br /> APPtACANT NAME L 0,. <br /> oRIVER'S LICENSE# r <br /> TITLE <br />