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San Joaquin County Environmental Health Department <br /> DATE <br /> MASTER FILE RECORD INFORMATION "MFR" GREEN FORM <br /> w•ns�.""",nFmo—n". OWNERID# vv�J 1�` b - 2 CASE# UNIT IV <br /> \\ OWNER FILE <br /> COMPLETE THE FOLLOWING PROPERTY OWNER INFORMATION; CHECKIF OWNER CURRENTIYONMEWITHEHD <br /> PROPERTY OWNER ���^'�� �.}- y�7\t! �/J PHONE <br /> `�NE�� }� <br /> NAME 4, (A 1 U 5/ / ' V <br /> First Ml �) �r last <br /> BUSINESS NAME I •(�",�_ Soc SEc/TAx ID# <br /> 0-4-iianre Addres! y /, �O /W,ifs/� ( L ✓•+1i7L� DRIVER'S LICENSE# <br /> _T city �A zip <br /> Owner Mailing Address <br /> Mailing Address City State Zip <br /> TVPF QF AWNFRGNTP �7 <br /> I•l aP .A_T .I^I T-ni LAI ^ DGPTJFPC F1 FF(1 Arr.N I I^ r•TTHFU I I <br /> FArIll 'Ty <br /> FACIISIY ID# n k S 43 CROSS REF ID# ACCOUNT ID# 1-\ INV# <br /> COMPLETETHEFOLLOWrNG BUSINESS I FACILITY I SITE INFORMATION,` <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 /> BusINEss/FACILm/SITE NAME <br /> SITE ADDRESSC SUITE# BUSINESS PHONE <br /> CITY v c-V A_1 r.k _ s�ATC A- ZIL17 LJ 0_3 <br /> _3 - 10 SS <br /> IIBOARD OF SUPERVISOR DISTRICT I ' LOCATION CODE I I KEMi _ <br /> Mailing Address if DIFFERENT from Facility Address Attention:or Care Of(optiFonal) <br /> Mailing Address City STATE ZIP <br /> SIC Co APN# CommENr <br /> THIRD PARTY BILLING INFO: Comp/eteif Billing Party isdifferent from Property Owner or Facility Operator identified above. <br /> BUSINESS NAME Attention:or Care Of (optional) , <br /> V?G l)r& 11 z'he Fte*.' ikxS <br /> Mailing AddressPHON Z� <br /> -3 C ►,c, �.n ti t uc 11� y1t�- �le <br /> crrr 12 J C I h STATFr ZIP s 7 <br /> �rY`n/rNT AjWgECC for fees and charges OWNER FACILITY/BUSINESS THIRD PARTY BILLING <br /> RILI.ING AND CONIPI.1ANC'R.ACKNOwTFDCAIFNT: 1,the undersigned Applicant,certify that I am the Owner,Operator,or Authorized Agent of this Business,and 1 acknowledge that all PERMIT FEES, <br /> PENALTIES,ENFORCEMENT CHARGES and/or HOURLYCHARGES associated with this operation will be billed to me at the address identified above as the ACC017\7ADDREX for this site. I also certify that all <br /> 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,1 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 available and at the same time it is <br /> provided to me or my representative. <br /> PLEASE PRINT <br /> APPLICANT NAMECA„h J^/� i n} SIGNATURE <br /> TITLE [� S, �r DRIVER'S LICENSE# <br /> a <br /> , � 1 i/ 2 L' �\I�6i:� z L- (PHOTOCOPY REQUIRED) J S <br /> Approved By Date Accounting Office Processing Completed By Date t C <br />