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f r San Joaquin County Environmental Health Department <br /> GREEN FORM <br /> DATE MASTER FILE RECORD INFORMATION "MFR" <br /> yw. aPNn cnxiv OWNER ID# 01 �o133� CASE# UNIT IV <br /> OWNER FILE <br /> CNECKIF OWNER CURRENRYON Foe Hz7N EHD <br /> COMPLETETHEFOLLOWINGPROPERTY OWNER INFORMATION; <br /> PROPERTY OWNER NAME PHONE <br /> First Ml Last <br /> Soc SEC/TAx ID# <br /> BUSINESS NAME /!WL o.w 1�0$ Q&C1 0 1NTLr1 <br /> Owner Home Address 11241 DRIVER'S LICENSE# <br /> e <br /> city / Ol R; STATE uPn 5�7 0 <br /> owner Mailing Address -764oq -1 <br /> �1 r ,sue, Pile Sw e. <br /> Mailing Address City STOLIC� staG Zip'T5219 <br /> TVGGrenw GacurG •.1 TO <br /> CORPORATION INDIVIDUAL El PARTNERSHIP❑ FEDAGENCY❑ OTHER❑ <br /> FACILITY FILE <br /> FACILITY ID# DO I (a./. CROSS REP ID# ACCOUNT ID At D„O dd10( q/ �I INV# n <br /> COMPLETETH F LL WIN l� NF ATI FF--VV �-00 lE / ,Ab�c •l <br /> Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES El NO IIN <br /> Is this an EXISTING Business LOCATION but a NEW TYPE of regulated Business?�{n I,��1 /^� Y ,YYESS ❑ No ya <br /> BusINESs/FAm.ITY/SrrENAME /l _ �Yf�Tro-tf,T,—' l`A-r- t),Vi 9v rm "er ( Z)n-� <br /> SITE ADDRESS sum At BUSINESS PHONE <br /> 197655 W. GraYd- L,'IA� RoT>� <br /> CM �rat STATE(--A nP 95 39 ) <br /> BOARDGFSUPERVLSORDISTRICT LOCATION CODE XEY1 REY2 <br /> Mailing Address if DIFFERENr from Facility Addre" Attention:or Care Of(optional) <br /> Mailing Address City _ 'STATE ZIP <br /> �I COMMENT: <br /> SIC CODE A #ZOq—Oto0- 31 <br /> THIRD PARTY BILLING INFO: is differentfrom Property Owner or Facility Operator identified above. <br /> Busiri ss NAME ttention: or Care Of (options/) <br /> vi ora - K k a T„ . i ,k Kew+- Bas <br /> Mailing Add ress ,,11�lt 1I _.- L1 r PHONE�4 <br /> 1I�0 W. >bM1 1�'L �IA1Tl.T- Q <br /> CITY 5 �tic.k 1 Of% STATE cA ZIP 952-19 C 2l 1 <br /> ercouAr Anowlic for fees and charges OWNER FACILITYIBUSINESS THIRD PARTY BILLING <br /> R (7ANrG AFRNOWI rnC.MENT: L the undersigned Applicant,certify that 1 am the Owner,Operator,or Aad iorized Agent of this Business,and 1 acknowledge that all PERMn'FEEs, <br /> PENALFIF,ENFORCEMENTCNARGcv and/or flour,IYGIARriB associated with this operation will be billed tome at the address identified above as the ACTOWFAnORFp'for this 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 STATEand/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 DEPAR MENT as soon as it is avaa e as d at the same time it is <br /> provided to me or my representative. 1, 1 LEA �-PR^IN-T- //Tq///�/f <br /> APPLICANT NAME SIGNATURE C/I/G" <br /> TITLE 5�LTer !�L /`!s /'���1 DRNER'SLICENSE# <br /> ✓ JILT} l) DRIVER'S(PHOTOCOPLICENSE <br /> Approved By Date Accounting Office Processing Completed By Date <br /> 29-03-002 April 25,2003 <br />