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San Jr—quin County Environmental Health Department <br /> DATE (� GREEN FORM <br /> v � - MASTER FILE RECORD INFORMATION "MFR" <br /> OWNER ID# T-vo 1 za,I Fc ;s #-I UNIT IV <br /> OWNER FILE <br /> LETF THE FOLLOWING PROPERTY OWNER INFORMATION' CHECKIF OWNER CuRRENnrONFzLEwrrNEHD ❑ <br /> PROPERTY OWNER1 PHONE <br /> NAME �� 1 ♦r♦�7 L rr t] L U 3 f7 <br /> First Mst 7l law <br /> BUSINESS NAME 1 Soc SEC/TAX ID# <br /> Q <br /> Owner Home Address } DRIVER's LICENSE# <br /> City ,'/♦y^y <br /> 1 ' � STA ZIP <br /> Owner MadingAddrrss <br /> ailing Address City ! Stater Zip C S" <br /> TyPr nF nwNrn_gR= J (� I I <br /> nPDnA ATTrfIL TNnrirthiini 1 1 Peoria......i i FFM arcrrry{ I (TTNFP 1 1 <br /> �r Irrv# <br /> Fae-ri rry Tn x�' ronre o FP Th A ' Aran ikr Tn it <br /> 11 thss a NEW Business LocATION not previously regulated try the ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ No S <br /> s this an ExisTiNG Business LOCATION but a NEW TYPE of regulated Business? YES ❑ No <br /> USINESS/FACILITY/SITE NAME <br /> (i t)Iti-ti s � d d ✓� � + 0 +'1 <br /> °isFss � � � -- � � � + SUITE# BUSINESS PHONE <br /> CITY } � ��i� SPATE ZIP <br /> ARD of SUPERVISOR DiSTRIt:t' LOcwTION LADE KEY1 I _r a I KEY2 <br /> Mailing Address ifDIFFERENTfrom FactlityAddress AtWnttop or Care Oftronal) <br /> U - T G I 7 �� V Zc —.e) —C)I L v v <br /> ailing Address City 1_, 4 k STATE` zip j <br /> C CaDE° s APN# - - a 1 <br /> COMMENT <br /> lRD PARTY BILLING INFO: Complete/f Billing Party Is different from Property Owner or Facility Operator Identified above <br /> BUSINESS NAME Attention or Care Of (optional) <br /> palling Address TPHONE <br /> rrT STATE ZIP <br /> ACMU rr ennoFc for fees and charges OWNER FACILITY/RUSimESs THIRD PARTY BILLING <br /> 1,the undersigned Applicant,terrify that 1 am the Oil tier,Operator,or Anthorred Agent of this Business and i itanoniedge that all PFR tttr FEFs, <br /> [LTTE),EAFORCEst6\T CIIAAGFS and/or 1I0t7RL1 C114RGES associated Hnh this Operation AIII be billed tome ai the address identi Red above as the(J;CCLN(�.L�A&DAF if for this site i also cerhfv that all <br /> information provided on this application is true and correct and that all regulated acti%thes Hill be performed in accordance Hith all applicable SAN JO%QUIN COUN7TV Ordinance Codes andfor <br /> Standards and STATE and/or FEDERAL Laws and Regulations As the undersigned oHner,operator or agent of the property located at the abose fJcdltV/sdc address 1 herebv authorize the release or <br /> and all results and cnvironrncnlrl assessmeui information to SAN JOAQUIN COUNTY F.i\VIRONNIENTAL .EAI TH DF FNT as soon as it is as fable and at the same time it a <br /> 1 ,ded to me ar my rcprescntatrve r <br /> PLEASE PRINT <br /> WNTNAME .—�, y r r SIGNATURE <br /> IVEER'S <br /> RIVLICENSE# r , n �� J' ♦ f PNOTOCUPY REOUIRED !vJ tJ I r� <br /> A Proved BY Date Accounting Office Processing Completed By Date <br />