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Ubi 13/ZUL12 14: 41 4b4k.1138 LHV 1KUI it i, ,I i NL. r-IGf-dL 117 rriur- U.J. <br /> �t (; , San Joa uin-U'0q)V I''`0b��� lttt';�5t3�l,IC 3 ' ;t!Lv1�dfL ���J.' �3[�: fY!$Jp r + # l <br /> ry <br /> GREEN FORM <br /> :)ATE MASTER FILE RECORD INFORMATION "MFR" <br /> 3 11801 .e81ee12aEt!9-YI1L91'vx 'r � Y !j �.�� of UNIT IV <br /> OWNER FILE <br /> COMPLETETHEFOLLOWINGPROPERTY OWNER INFORMATION: CHECKir OWNER CURREHTLrONf/LEN'IrHEHD <br /> PROPERTY PHONE / / [��/ V <br /> OWNER NAME rfi t J �L L U/�✓� 7 -7b " (// ! () /( O!7 <br /> F'.1 Mr bN <br /> 8usmrss NAPE f r� / I ��' -y/��'/.?r G L SOO SEC/TAX ID A . <br /> Owner Home Address (tel DRIVER'S LICENSE <br /> City Zloc) �L Lj�-S-F 6/4,v,1 //•4/I/ STATE ZIP <br /> OWnsr Moiling Add-ea <br /> Melling Address City 2 5-3 -7 —7 State Zip <br /> CORPORATIO IN0IVIOVAL 13 PARTNERSHIP O FED AGENCY OTHER <br /> F1Z 3 FACILITY FILE <br /> 1,i-'" f'1 Y+�+ .r( Voll:: ! W'+t"'i `IVtFc alt•'. �ncwR n.'<.t 4 Ju.= WNr{y'F invq..- r,;i.. ..: h;if t_- <br /> ( 1.:. CWtff.�Dr1 <br /> COMPLETE THE FOLLOWING BUSINESS I FACILITY I SITE INFORMATION: <br /> Is this a NEw Business LOCAmm not previously regulated by the ENVIRONMENTAL HEALTH DlvtsloN 7 YES O Ng Pi— <br /> la this an EXISTING Business LOCATION but a New TYPE of regulated Business 7 YES 0 N <br /> BuslNEssIFACILITY/SITE NAME <br /> SITE AOoRE9s ' SUITE 0 BUSINEss PHONE <br /> CITY ( / STATE 04 ZIP 7 7 (� I <br /> ., �IJhrr,•�;�nir'6� <br /> 7 <br /> O�OF,bVPERVIBORJ_11,. hr <br /> 4A 00 D6:6IE, <br /> Mailing Address IfOIFFERE/VTfrom FecllltyAddresi Attention:or Care Of(opt/onal) <br /> Mailing Address City STATE Zip <br /> THIRD PARTY BILLING INFO: Complete If Billing Party Is d/H`ierent from Property Owner orFaclllty Operator/dentlbedabove. <br /> BUSINESS NAME ' Attention:or Care Of (opt/onll <br /> s <br /> Melling Address 22- ( „t, S G 0 <br /> S' <br /> CITY STATE C + ZIP C / <br /> � ( a <br /> ACCOVNTADDRE$S for foes and charges OvVNER FACILITY18uSINESS THIRD PARTY BILLING <br /> IIILI.INC^Nn COMPLIANCE ACKNOWI.r"nGMENT: 1,the undcnigned ApplicAnt.certify thAl I nm the Owner,Operator,or ANtbprited Agent of Ihlc lIhisiness.and 1 aeknowledae thnt Fill <br /> PCRAtrT FI'RT,PENALrirN,F-Nr0RCf.MPNT C11Alt[iCT and/or H0(,'Rr.V(_IfARCFJ A!RnclAtcd with Ihls operation will he billt+l to me At the address kleall(ed Above ae the AM)uNrAnI IT <br /> for this 3{It 1 also artily that All(nformalion provided on this Application is True and correct;and 1hAl all regulated activities will be performed is accontnncc with all appli"blc SAN <br /> .IOAOIIIN COUNTY Onlinanet Cadet and/nr StAndAnte And STATE and/or FROFaAI,Laws anti ION <br /> As the aadenlgnal owner,operntar,or sgtel of the property touted nI the <br /> above faelllryhlte Addrest. 1 hereby authorize the rrlcAae_rn <br /> c of Any and all rht And envlronmenUl AIf.gVsmtnt Info <br /> rmAtloa la Jf1AQlIIN Cnll!'1'1' �NVIR MFNTAI. <br /> IIEALTH DIVISION as soon no It Is AvaBAble and at the utne time ilk provided to me or my repreoestative. <br /> PLEIA3F PRINT <br /> APPLICANT NAME /-/D L / S' %�/��1 L i f SIGNATURE <br /> DRIVER'S LICENSE Af- <br /> �,� dLv6/1 r <br /> TITLE t J - rmcnl <br /> Fi+rlF'� �.•,rt'ai[ r.r.ao-.e1.. y,. e.i.r�' t..' 1► �r Y" V"S�1„�r �� <br /> "AoocIu In2, pe- roa <br /> �- <br /> Post-iN Fa C 7671 Dale +I pa0gas <br /> 10.1 <br /> To / From <br /> 1 <br />