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San Joaquin County Environmental Health Department <br /> GREEN FORM <br /> DATE MASTER FILE RECORD INFORMATION '"MFR"'.S`u. uFun unu,• OWNER ID# 0�0o133a�j CASE# UNIT IV <br /> OWNER FILE <br /> COMPLETE THEFOLLOWINGPROPERTY OWNER INFORMATION: CHEO(IF OWNER CURRENILYONFILEWIM EHD <br /> PROPERTY OWNER NAME PHONE <br /> First MI Last <br /> BUSINESS NAME SOC SEC/Tax ID# <br /> C-6K� ov.:11e5 oral a Wts.v. <br /> Owner Horne Address 11244 Gol g1v �y�;}� IQD DRIVER'S LICENSE# p <br /> CRY STATE <br /> / el ^K; ZIDq S(e70 <br /> Owner Mailing AddressC <br /> 764p P IiNc. f�Ut! Jri t, <br /> Mailing Address City G 1 Gk 1 StaG zip Q 52101 <br /> TVOFOFOWNFOC ro JTD T8 <br /> CORPORATION INDMDUAL❑ PARTNERSIgP❑ FED AGENCY❑ OTHER❑ <br /> FACILITY FILE <br /> FACIIITYID# OD'1.-I CROSS REF ID.# ACCOUNTID# D INV# <br /> Is this a NEW Business LOCATION ff(�f1not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? (�OYEs(E No <br /> Is this an EIDSTING Business LOCATION but a NEW TYPE Of regulated Business? YES ❑ No <br /> BUSINESS/FACLITY/SIIENAME `f - - VS,� 5krrt, �.laer Pon" <br /> SITE ADDRESS SUITE# BUSINESS PHONE <br /> Mass k7, Gt•a.YLfi Li1Ae. Road <br /> Cm �roc STA�A ' q'5311 <br /> BOARDOFSUPIEFEMORDISTR1Cr LOCATION CODE KEYl KEY2 <br /> Mailing Address/fDIFFERENrrrom Fad//IyAddresa Attention:or Care Of(options/J <br /> Mailing Address City STATE Zip <br /> DE A <br /> SIC CO #g O 1-0(.0-31 <br /> -1"O(oO—3 I COMMENn <br /> THIRD PARTY BILLING INFO: L Is djfierent fmm Property owner Of FBCliity Operator%l endf/E'd above. <br /> BUSINESS NAME''� T ttention:orCare Of (opHonaQ <br /> Lt/aj 0'c. - SOCA eS J-vL 1 r.k eh�- a5 <br /> Mailing Address PHONE <br /> 0 IAT- � �e 541�� 204-21 -772 <br /> C[TY I 1 OH STATE (f'T. /t ZIP ,S�'�l Q <br /> AccaLmi Aaaam for fees and Charges OWNER FACILITY/BUSINESS THIRD PARTY BILLING <br /> R •r rn Pr IANre ArxNOWr FDCMFNT; 1,the undersigned Applicant,certify that I am the owner,operator,or Authorized Agent of this Business,and 1 acknowledge that all Pe2Nrr Fees, <br /> PEAd rre,EnFmtcE>fE'M'CII Es and/or HoUIrLy CN GeYassociated with this operation will be billed tome at the address identified above as the AMOVATAQDIUNS 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 JOAQUIN COUNTY Ordinance Codes and/or <br /> Standards and STATE and/or FEDERAL Laws and Regulations. As the undersigned owner,operator,or agent ofthe property located at the above facility/site address,1 hereby authorize the release of <br /> any and all results and environmental assessment information to SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARMENT as soon as it u ovaffl��teeebre a d at the same time it is <br /> provided to me or my representative 1/ 1� PRINT <br /> APPLICANT NAME jc of ELS keaa,+ M� w SIGNATURE <br /> TIRE 1t� /}�f}� '/+l �(T� DRIVER'S LICENSE# <br /> -5eAlor lam-` ` Gee("I f (PHOTOCOPY REQUIRED) <br /> Approved By pate Accounting Office Processing Completed By Date <br />