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DATE GREEN FORM <br /> IL I MASTER FILE RECORD INFORMATION "MI" <br /> UNIT IV <br /> OWNER FILE <br /> COMPLETE THE FOLLOWING PROPERTY OWNER INFORMATION: CHECK F OWNER CURRENTLY ON FILE WITH EHO a <br /> PROPERTY TAe /155lChR/C+•T4�6(e % Eis'tr��� �d PHONE <br /> OWNER NAME GLrnll/nalGr. �//L(JS — (20-1) X78 4OZ <br /> r.x w+ uaI <br /> Busmrtss NAME SOC SEO I TAx 1D N <br /> Owner Home Address 90� 1i 1 / vu I DRIVER'S LICENSE 3 <br /> City $TATE e� Zlv IS.Z�C <br /> Ovmer Haling Addrata <br /> Mailing Address City State Zip <br /> CORPORATION❑ INDIVIDUAL❑ PARTNERSHIP❑ FED AGENCY❑ OTHER t] <br /> FACILITY FILE <br /> ,� , �a ,•utsrl,,. .,:�. - <br /> COMPLETETHEFOLLOWING BUSINESS/ FACILITY/ SITE INFORMATION.- <br /> lot this a NEw Buslnesa LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DIVISION 7 YES ❑ NO g, <br /> Is this an E1t13TINC Business LOCATION but a NEw TYPE of regulated Business YES ❑ No (� <br /> BUS[NESSIFACILITYIS+TE NAME .,y� �— <br /> //lf�iL��R /�L,2teL <br /> SITE AOORESS SUITE N BUSIME33 PHONE <br /> CITY STATE LP <br /> ARO 6F SHAEr2Y1QOR,' r` C � I �WiY� <br /> tul <br /> Mailing Address ifO/FFERENrfrom Facility Address Attention: or Care Of(optional) <br /> 25-0 E. rF Mg jo t <br /> Mailing Address City be // STATE n� Z:► �IDOQ - <br /> ..: . tin: , ke ,: ` _ -- •• � = ` J O - <br /> ti . <br /> sIC'bboe� �=.. _: ::.... _ :._ �IPlys. ,.. Cpa►eerti= - - - - - - .f - <br /> ?'HIRD PARTY BILLI`O INFo: Complete if Billing Party is different from Property Owner or Facility Op,:-ator identifiedabo.-ii. <br /> BUSINESS NAME Attention. or Care Of (optional)- <br /> tLJ C /•rl X02 <br /> Mailing Address2 SD /t PHONE cQOa ) 8 3( - o 8 <br /> Cm 3Ej <br /> / / c / I <br /> C'- STATE ^ ,� LP � <br /> ACC0uNTAat7REss for fees and charges OWNER FACILITY/BUSINESS THIRD PARTY BILUNG <br /> '111-LINC AND COMPLIANCE ACKNOWLEDGMENT: 1,the undersigned Applicant,certify tbat I am the Owner,Operator,or Authorized.lgent of this Business.and I acknowledge that all PER417FEES. <br /> 'E,VA4r7P.K E.14F0RCENFvTCHARGE.T and/or HocitLircmA tGu associated with this operation will he billed to one at the address identified above as the.ICCOGiVrADDREXT for this site. 1 also certify that <br /> LU information prnvided on this application is true and correct;and that all tegrdstad activities will be performed in accordanot with all applicabk SAN JOAQUIN Cou,#4TY Ordinance Codes and/or <br /> itandards aril STATE and/or FEDERAL Laws and Regulations. As the undersigned owner,operator,or syem or the pr-perry located at the above racilityisite address.I hereby Authorize The+elase of <br /> my.Ind all resulb nod environowntal assessment information to SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DIVISION as soon as it is available and at the same ome it is provided to <br /> ne or my representative. <br /> SE PRINT <br /> APPLICANT NAME Ee2t`C Z Ir"/`'" SIGNATURE r� <br /> / �'�I�'`�''�- / DRIVER'S LICENSE 9 3 <br /> TITLE \ ]C.� �GOf B�l S f (PHoroCOVY REQU+REO) e4gz8 - <br /> i RRq�rtE�651✓, -, s�, ,��I �' ,� c- -+- �GGQ+Mtd344 C�'QCI�t✓�W�RJl1i�lOkQS�I�`J:_ __ �� �. :Date- _. _ -. <br /> !C� 6 ICZS <br /> 6c6 L—L <br />