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San Join County Environmental Health impartment <br /> GREEN FORM <br /> DATE w,3 V v MASTER FILE RECORD INFORMATION A%MFRrr <br /> qHawFriARFAS FOR Fun I ICF nwv OWNERID# S'7�S' # UNIT IV <br /> OWNER FILE <br /> LY/EG OWNERLLxe£xrtroxrTc£wrnt EHD <br /> COMPLETE THE FOLLOWINGPROPERTY OWNER INFORMATION; HO Q <br /> F410MIYOyINERNAME O� DV <br /> F <br /> First MI Last <br /> BUsmF55 NAMEI I ,•,_ J. , _ I�.�v " UIS Soc SEc/TAx ID# <br /> Oamer Home Addd�rH��!/1'�/A�w/•�I�(ru�u J �/�1 DRrVEIeS LIEENSIE# �y <br /> city <br /> 1- ST.- Z1P (A GJ� <br /> 73 <br /> Owner Mailing Al//ddlf'eress•', (sAtu p, l <br /> Mailing Address City IK6 r 9t<l" state Zip <br /> TVpF M r1WN.e. 97 1 <br /> CORPOrNTION� INDIVIDUAL❑ PARTNERSHID❑ FEDAGMUD mot El <br /> FACILITY FILE <br /> FAaLm ID# O 1.3 CROSS REF ID I AccouNr ID# I D O I INV# <br /> PLETE THf FOLLOWING RMATION- l� <br /> Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ No ❑ <br /> Is this an EXISTING Business LOCATION but a NEW TYPE Of regulated Business? YES ❑ No ❑ <br /> BusmEss/FACKLTY/SIrENAME , 1 0?Pf '(W <br /> SREADORISS �'l(J/' 1�'✓L�C� f rl�'` p tV11y_ SDITE# BUSINESS PHONE <br /> CITY -MCV—To 0 STATE - ZID/A`�1 52W <br /> BOARD U <br /> OF SsimissOR nt <br /> Dlstcr LOCATION CODE KEYL KEv2 <br /> Mailing Address if DIFFERENT from Facility Addressc Attention:or Care Of(optiorw/J <br /> Mailing Address City STATE zip <br /> SIC CODE/.yv �/✓ APN# S-0 3 Z)D b COMMENT: <br /> THIRD PARTY BILLING INFO: Complete if Billing Party is different from Property Owner or Facility Operator idendfied above. <br /> BUSINESS NAME Attention:orCamOf <br /> kw me�rSi <br /> PHONE 5tb 5�s/I ��I� <br /> Mailing Address �r� i D2 o If I I <br /> �Y OYy 1 1 N). 1• <br /> QWUAAmWw^l gEsssfftorfees and charges OWNER FACILfry/BUSINESS TTHIRD PAR`TY�BILLWING <br /> revrr ArKNnwr Fur.MENT: 1,the undersigned Applicant,certify that 1 am the Owner,Operator,or Autharized Agent of this Business,and 1 acknowledge that all P£RAuT FEES, <br /> pE ,,Es,EN zzaceTsu rvT Ctan Ga and/or HOOAEY CHARGES associated with this operation will be billed tome at the address identified above as the AMQIIAT ADDRF.eC 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 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 DEPARTMENT as soon a it is <br /> available d at the same time it is <br /> provided to me orN my representative. NATURE <br /> APPLICANT NAME )/� 1 ,1T �y�(tR���y� P�EPRutr SIGSE TI*1/Y'r�./��/� 1 <br /> TITLE '"[ J f��L li� S/yT rr �✓1 DNOTIOCO REOUNIRED) �7 • �J 1 <br /> Approved By I� Date Accounting Office Processing Completed By !y�- <br /> 29-02-002 April 25,2003 �..I L <br />