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San Joaquin County Environmental Health Department <br /> GREEN FORM <br /> MASTER FILE RECORD INFORMATION "'MFR" <br /> ;�n ucFnNiv - UNIT IV <br /> OWNER FILE <br /> - LL0 KING P RO P E RTY OWNER INFORMA7ToN; CHECKIF OWNER CURRENTLYONFILE WITH EHD ❑ <br /> 1AME PHONE <br /> First MI Last <br /> s,E �4�EGLU.S T/L� Llie,. � <br /> SO:SEC,TAxID# <br /> Home Address DRIVER'S LICENSE# <br /> Cjty STATE ZIP <br /> Owner Mailing Address <br /> Mailing Address City v•/ c c'u�0 l State Zip <br /> TYPE nF n WNFR 6{IP f <br /> CORPORATION❑ INDIVIDUAL❑ PARTNERSHIP❑ FED AGENCY❑ OTHER❑ <br /> FACILITY FILE <br /> FAQtITYID# L I CRINV# <br /> OSS ACCOOtIrID# J r' <br /> COMPLEZE E NISINESS FACILITY I SITE INFORMA77ON: <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 rpgulated Business? YES ❑ No <br /> SUSINE5S/FACILITY/SITE NAME / •�Ly.+�GI / I)� <br /> SITE ADDRESS / ��✓/ • ' C•• A �y— SUITE# BUSINESS PHONE <br /> CITY STATE ZIP (T Os) W <br /> Mailing Address ifDIFFERENTfran FadlityAlddress Attention:or Care Of(optional) <br /> Mailing Address City STATE ZIP <br /> THIRD PARTY BILLING INFO: Compieteif Billing Party isdifJrerentfrom Property Owner or Facility Operator identified above. <br /> Bt>SatEss NAME Attention:or Care Of (optional) <br /> AV. 5Go-r N-N ,4067- <br /> Mailing Address l4oD/ ' f�!//�-�f/ �91 /_ / <br /> CITY PHONE ���• � lfyr <br /> rt STATE� z- �✓�3 <br /> d/Y'aLmT d/DRLiY for fees and charges OWNER FACILITY/BUSINESS THIRD PARTY BILLING <br /> BII I INt'AND f'o�t1Pi IANrF AcKNn%yi FurmP T: 1,the undersigned Applicant,certify that 1 am the Owner,Operator,or Authorized Agent of this u tat all PEPwn-FEES, <br /> PENALTIES,ENFORCEN£NTCXARG£S and/or HOURLYCHARGFS associated with this operation will be billed tome at the address identified abore as theACrYHLVTADnRT'SS(or 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 available and at the same time it is <br /> .provided to me or my representative. '/Q <br /> R77JT A / 0 <br /> APPLICANT NAME PLEASE PSIGNATURE r-- <br /> TITLE DRIVER'S LICENSE# <br /> (PHOTOCOPY REQUIRED) <br /> 6-11 <br /> APW-,.d By Date Accounting Office Processing Completed By Date <br /> 29-02-002 April 25,200 <br />