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San Joaquin County Environmental Health Department <br /> � GREEN FORM <br /> DATE y�rj MASTER FILE RECORD INFORMATION "11MM" <br /> CNenFn eocec ono FNn imp nNi v OWNER ID# F'9 P051,;2- <br /> CASE# UNIT IV <br /> OWNER FILE <br /> COMPLETE THE FOLLOWING PROPERTY OWNER INFORMATION. CHECK IF OWNER CURRENnYONFrLEw1TH E H D ❑ <br /> PROPERTY OWNER NAME PHONE <br /> First MI Last <br /> BUSINESS NAME /k o � SOC SEC/TAx ID# <br /> oa � o �.� - 3 <br /> Owner Home Address 2 2 Z) ` W 1 DRIVER'S LICENSE# <br /> City S A, STATE � '\ � \S Z- <br /> � 3 <br /> Owner Mailing Address c O$4 <br /> Mailing Address City s c f State C k Zip S 2 0 <br /> TVOF OF nwNFggm ,t-O <br /> CORPORATION❑ INDMDUAL❑ PARTNERSHIPS FED AGENCY❑ OTHER <br /> FACILITY FILE <br /> FACILITY ID# h ^ CROSS REF ID# ACCOUNT ID# lfnwa& <br /> INV# <br /> BUSINESS I FACILITY SITE INFORAIATZON.' <br /> Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES El No <br /> Is this an EXISTING Business LOCATION but a NEW TYPE Of regulated Business? YES ❑ No <br /> BUSINESS/FACILITY/SITE NAME �q �tT-- D � � l0 <br /> SITE ADDRESS VV 11 L1�- f SUITE# BUSINESS PHONE <br /> CITY I v STATE ZIP <br /> BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEYI KEY 2 I <br /> Mailing Address ifDIFFERENTfiom FadlilyAddrEss Atbention:or Care Of(optional) <br /> Mailing Address City STATE ZIP <br /> SIC CODEAPN# COMMENT: <br /> THIRD PARTY BILLING INFO: Complete if Billing Party is different from Property Owner or Facility Operator identified above. <br /> BUSINESS NAME Attention:orCare Of (optional) <br /> Chi,• lb h,Jlt..n \ ��G S 2C �. QrS O c <br /> Mailing Address PHONE <br /> Cm �Gl 1•n ..� `-�-G�- �.- STATE � ` ZIP A + <br /> Accmwrennccte for fees and chargesf� <br /> OWNER FACILITY/BUSINESS ARTY BILLI <br /> RII I I]GAin CnvePLiA�rE ACK\OWI.Fn"NIENT: 1,the undersigned Applicant,certify that I am the Owner,Operator,or Authorized Agent of this Busi s,and 1 acknowl that all P£RSI7T FEES, <br /> PENALTIES,ENFORCEMENTCHARGEs and/or HOURLY CHARGES associated with this operation will be billed to me at the address identified above as the 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 COL\TY 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 /> �S p 1 � PLEASE PRINT <br /> APPLICANT NAME T $IGNATUR� <br /> TITLE DRIVER'S LICENSESEE# T� <br /> C-O`C> 5� (PHOTOCOPY REQUIRED) Y t C) <br /> A,proved By Date L C C Accounting Office Processing Completed By Date D <br /> 29-02-002 April 25,2003 <br />