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12/21/2006 12:05 FAX Z002 <br /> San Joaquin County Environmental Health Department <br /> GREEN FORM <br /> DATE 12/2n/04 MASTER FILE RECORD INFORMATION ""MFR" �Tl <br /> '5gp cna FecroaFHn ucr rINLV_ OWNER ID# CASE# N Y <br /> OWNER FILE <br /> COMPLETETHEFOLLOWINGPROPERTY OWNER INFORMATION; CHECKIF OWNER CURRENTLYONPIL£WlTH EHD ❑ <br /> PROPERTY OWNER NAME 1HONE <br /> --Fire! <br /> BUSINESSNAME � SOC SEC/TAX ID# <br /> ' v �- L <br /> Owner Home Address DRIVER'S LICENSE# <br /> City STATE ZIP <br /> Owner Mailing Address l I of L <br /> qq /OI J /'p� &IV ) �u tilNO <br /> Mailing Address 01 `Lv7 ( <br /> Cityd t State (- Zlp 15-470 <br /> TYPF nF r1wNFRcHIP <br /> CORPORATION INDIVIDUAL❑ PARTNERSHIP❑ FED AGENCY❑ OTHER❑ <br /> FACILITY FILE <br /> � l INV# <br /> FACIurY ID# —� CROSS REF ID# ACCOUNT ID# „ <br /> ETETHEFOLLOWING BUSINESS I FACILITY/ SITEINEORMATION' y <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/FAcmm/SITE NAME ��1 L <br /> J c► ne ar <br /> SITE ADDRESSr6 s r <br /> CITY �" �I�C Sum# BUSINESS PHONE <br /> �f S�nTE� ZIP 5.3 Q <br /> BOARD OF SUPERVISOR DISTRICT III LOCATION CODE KErl KEY2 <br /> Mailing Address iFDIFFERENT from Facility Address Attention:or Care Of(optional) <br /> Mailing Address City STATE ZIP <br /> --ISIC CODE CPN# COMMENT; <br /> THIRD PARTY BILLING INFO: Completeif Billing Party is difiorent from Property Owner or Facility Operator identified above. <br /> BUSINESS NAME Attention:or Care Of (optional) <br /> So G <br /> F <br /> ania ddress C 14 [- " �9 Z -7 7 <br /> Cm564r-�Vll f [' S7n7E ZIP <br /> errnrrerreneaacr for fees and charges OWNER FACILITY/BUSINESS T D PARTY BILLIN <br /> RILLING AND CONIPLIANC'E ACKNO\V LEDGNIEN'1': 1,(lie undersigned Applicant,certify that 1:1111 the Owner,Operator,or Awhorred Agent of this Business,and I acknowledge that all PLR,AIIT PEts, <br /> PENALTIES,ENFORCEAIEN'T CH fnCL'.4 and/or HOURLY CH.4RGE5 aSsoriated with this operation Ns ill be billed to meat the address Identifled above as the ACcouxTADDRE4C for this site. I 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 JUAQUIN COUNn Ordinance Codes and/or <br /> Standards and STAT/'.and/or FEDERAL Laws and Regulations. As(lie 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 av 'labie and at I some time it is <br /> provided to me or my representative. L�n <br /> IL <br /> APPLICANT APPLICANT NAME����' t— & {�SE Z SIGNATURE /� <br /> TITLE -5 Lar L 6 GO(O I� - 1 kR DRIVER'S LICENSE# 163 7' 35 1 1 <br /> j rT��W��iG����' SSQC./ (PHOTOCOPY REOUIRED) <br /> Approved By Date Accounting Office Processing Completed By Date <br /> 29-02-002 April 25,2003 <br />