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San Joa%juin County Environmental Health L,Nartment GREEN FORM DATE a t3 �2P I 0 "MASTER FILE RECORD INFORMATION MFR"f &mAnFn AYFIC Fno FMn uSF Our v OWNER ID# CASE# UNIT IV OWNER FILE COMPLETETHEFOLLOWZNGPROPERTY OWNER INFORMATION; 0MCKIF OWNER CURRENrzYONMEWrrrt EHD PROPERTY OWNER NAME PHONE 1, 2, - Z%A S -✓ L�UT First MI (� Last `J BUSINESS NAME ^C p , r C Soc SEc/TAx ID# Owner Home Address DRIVER'S LICENSE# City '/ ✓ STATE zip Owner Mailing Address Z 5 C}_C) So eo Mailing Address City / Vy1C.A'; state ZiP Cris`� 1 TroF nr.f1wmFRsHTD l' CORPORATIOWU. INDIVIDUAL❑ PARTNERSHIP❑ FED AGENCY❑ OTHER❑ \\ FACILITY FILE k�,[)# CROSS REF ID# ACCOUNT ID# INV# COMPLE7F 7HE FOUOWLNGA Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ No ❑ Is this an EXISTING Business LOCATION but a NEW TYPE of regulated Business? }� YES ❑ No ❑ BUSINESS/FAQLrrY//SITE NAME Ne'i � ,� l� �,.,/�� J` V a —vos I .c `Pro r+ti SITE ADDRESS y_1 PN' '� Y I _'` - , ^, -�/ �7 I SUITE# BUSINESS PHONE aTY v'Ylc�>`�1 r" `'^ °J�1"N� �"1�J(J (� (� (i l I yrATE � ?;a 1 I BOARD OF SUPERVISOR DIsmcr 1 LOCATION CODE KEY1 KEY2 Mailing Address/fDIFFERENTfrom Fad/ityAddr,ess Attention:or Care Of(opbona/) Mailing Address City STATE zip IFF.- 1[APN# COMMENT: THIRD PARTY BILLING INFO: Complete if Billing Party i5 different from Property Owner or Facility Operator identified above. BUSINESS NAME I rr �-� Attention:orCare Of (q donaQ Mailing Address �/ I C r PHONE Cydj CITY a-v-\ � C C- STATE ZIP 1 S 3-e erYyyrwrr paaaa for fees and charges OWNER FACILITY/BUSINESS THIRD PARTY BILLING RIF I ING AND COMPr.1ANCE.ACKhLQMLELW.NfENT: I,the undersigned Applicant,certify that I am the(honer,Operator,or Authorized Agent of this Business,and I acknowledge that all PERAOT FSEs, PinALTms,ENFoR[Emi N CriaRGES and/or HouRLYCttaxcFs associated with this operation will be billed to me at the address identified above as the ACCOUNTAunRFcc for this site. I also certify that 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 COLIN'rV Ordinance Codes and/or 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 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 providedAPPLICANT to me or my representative. I r �n P VVI APPLICANT NAME �1�Irl�.ytK �Vr,l��S �1P.I�Pr LrV� SIGNATURE / 1f� TITLEj o r)/"iI S + Y DRIVER'S LICENSE#if l.."C.l.i 1 (PHOTOCOPY REQUIRED) Approved IY Date Accounting Office Processing Completed By Date 29-02-002 April 25,2003