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0 <br /> San Joaquin County Environmental Health Departme""E�l��� <br /> DATE �I_ MASTER FILE RECORD INFORMATION ""MFR" FEB 2 Z �, <br /> n;n RFec FnR FHn ncF nNJ v OWNER ID# CASE# N If iv <br /> ' <br /> OWNER FILE i F <br /> CNECKIF OWNER[()RRENTLYON FILE WITH EHD ❑ <br /> COMPLETETHEFOLLOWING PROPERTY OWNER INFORMATION; <br /> I PHONE �� 5 <br /> PROPERTY OWNER NAME t� Y� I \,N rJ S ) M C2 C) <br /> First MI/' X Last <br /> (� J } r 1 n SOc SEC/TAx ID# <br /> BUSINESS NAME <br /> r 1 JCC L. <br /> \ DRIVER'S LICENSE# <br /> Owner Home Address 13 1 �1; 1 G 1 <br /> JJ ZIP <br /> / I� <br /> city n� <br /> CA1 <br /> Owner Mailing Address <br /> State Zip <br /> Mailing Address City <br /> TVRF nF OwNFRCNTD <br /> CORPORATION❑ INDIVIDUAL❑ <br /> PARTNERSHIP FED AGENCY❑ OTHER❑ <br /> FACILITY FILE <br /> FAQUTY ID# CROSS REF ID# <br /> ACCOUNT ID# INV# <br /> P Th( F <br /> Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ No <br /> Is this an daSTING Business LOCATION but a NEW TYPE of regulated Business? YES ❑ No (� <br /> ' BUSINESS/FACIISTY/SITE NAME L/1 v C ��I r1 `VVe. `, .J �. <br /> SITE ADDRESS SUITE# BUSINESS PHONE <br /> Crr.' STATE(A ZIP I SCT O <br /> l <br /> BOARD OF SUPERVISOR DISTRICTj-- KEY1 KEY2 <br /> LOCATION CODE <br /> Mailing Address if DIFFERENT F %ityAddressjP <br /> rttion:or Care Of(options/) <br /> O <br /> 1 r� Mailing Address City /� �- STATE n 2 2-o <br /> SIC CODE APN# COMMENT: <br /> THIRD PARTY BILLING INFO: Complete if Billing Party is differentfmm Property Owner orFa ilcorCaityre OpeOf rator <br /> identified <br /> d en ified above. <br /> AttentiBUSINESS NAME <br /> PHONE <br /> Mailing Address <br /> STATE ZIP <br /> CITY <br /> ervnrna for fees and charges OWNER FACILITY/BUSINESS THIRD PARTY BILLING <br /> Rn+me AND f On•Pt+aNCF ActcNow+.Fncmcnr: 1,the undersigned Applicant,certify that I am the Owner,Operator,or Authorized Agen[of this Business,and 1 acknowledge that all PERMIT FEES, <br /> PENALTIES,ENFORCEMENT CHARGES and/or HOURLY CHARGES associated with this operation will be billed tome at the address identified above as the A Co RTA Dfi=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 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 as it is availnbk.-an t the same time it is <br /> provided to me or my representative. <br /> APPLICANT NAME P PRINT SIGNATURE <br /> DRIVER'S LICENSE# <br /> TITLE �7 (PHOTOCOPY REQUIRED) <br /> Approved By L- Date 2 C 7 D Accounting Office Processing Completed By Date <br /> 29-02-002 April 25.2003 <br />