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San Joaquin County Environmental Health Department <br /> GREEN FORM UNIT IV <br /> DATE �j Yti Y(?U MASTER FILE RECORD INFORMATION "MFR" <br /> SHAaEW 9.&ELtlD�a€9.Nkr owNen 109p�j0�0 \ cAnea <br /> o u+ <br /> OWNER FILE <br /> COMPLETE THE FOLLOWING PROPERTY OWNER/NFORMA770N,' CNECNNF OWNER CORRENn roNRLE WnH END <br /> PROPERTI'OWNER NAME PHONE 3 <br /> Fvst MI Last <br /> BUSINESS NAME �r ,l O O �1 f1 fiv//1 O s /I tl ({may SOCS.ITA%IDM <br /> Owner me AdtlVraee n /� Y• IL Y Y/l/ )`f 11(� / `• i• DRIVER'9ALICJF�NSEY <br /> CHy S U laY 1 V STATE CIA zip <br /> 'J Y v✓� <br /> llvmer Magi a Atltl s v <br /> Melling Address City state Zip <br /> CORPORATOR❑ INOMWAL❑ PARTNERSHIP❑ FW AGENCY❑ OTHER <br /> FACILITY FILE <br /> FACILITY IDtl CROSS REF IDS ACCOUNT IDS O ,r ra 11 INvtl ��$�i <br /> 3 �'S <br /> COMPLETE THE FOLLOWING BUSINESS I FACT LITY I SITE INFORMATION.' <br /> Is this a NI Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPT.? YEs ❑ No if <br /> Is this an EAfnING Business LOCATION testa NEVITYPE of regulated Business? YES ❑ No LN <br /> BusINESSFAML"I'SRENAMEAyla -kA <br /> r< '4 <br /> SRFADIXNE9er �Otr S 3 03 SURES S I ESSP NE Nba <br /> CITY ✓1 �� " STATE LP <br /> BOARDOF UPSOR LOCATION CODE KEY; <br /> Melling Address HDAFFERENTIrom Fac/NNyAddrreas Attention:or Care Of(0tabonal) <br /> Mailing Address City STATE ZIP <br /> SICCOW APN0 COMNEM: <br /> THIRD PARTY BILLING INFO: Complete ifBilling Party is different fromProperty Owner orFacility Operator identi le above. <br /> BUSANES9 NAME <br /> Atttion:orCare of (ophanato �I"v <br /> g <br /> fas <br /> Halling ren f I Q. PHONE L' ' O <br /> Cm v STATE UO'eaP r <br /> 'tel <br /> AMaIL rA MIS for fees and charges OWNER FACILITY/BUSINESS THIRD P RTY BILLING <br /> BILUNO ND COMr1,1ANCD A9N1!11 EDCMEr.Y: 1,the undersigned Applicant,certify that Iain the Ooner,Operator,or Amhorized Agent of this Budneas. a Ilowiedge that all PERMIT FESS <br /> PEVAEnn ENFORGP.AEw CnA ev and/or NiofmcY CHARGES associated with this operation will be billed to mat the addres,Identified above m the ACCOVNTADDRESf for this site. I also cerfity that <br /> all Infornlallon provided on this application Is Iran and correcr,and that all regutated activities will be performed In accordance with all applicable SAN JOAQUIN f RUNTY Ordinance Codes atl&or <br /> Standards and SrAlt aMUOr'FEDDRAL Laws and Regnladons. As the undersigned owner,operator,or agent of the property located at the above feelhty/site address,I llerebv authorize the release of <br /> any and all results and envlronnseulal assessment infonmadon to SAN JOAQUIN COUNTY ENVIRONMENTAL 11EALTIIB[(' PARTMENT as soon as If Is available and at the sasce time it Ls <br /> provided to me or mY representative. d'v' (SIGNATURE a� - <br /> i /I PLEASE PRIM QCs'✓/ <br /> APPLICANT NAME M Qll to rel� {"jY11N(I(/ � <br /> TITLE /d DRIVER'S LICENSEa� rg� H 'G <br /> IL fPHOTOC PY R.....E* <br /> OVIR ' ) ] Td's <br /> Appravad ey once Accour,Unn Ofics Proessetna CmmplebdeY once Zl D <br /> MASI'EKI'MEREC RD-GREEN <br /> 29-02 10112/07 <br />