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San Joaquin County Environmental Health-Department (� GREEN FORM DATE 2 ) ' MASTER FILE RECORD INFORMATION "MFR" sHanFn ARFAs Fna FH n nsF rnso v UNIT IV OWNER FILE w t) L) S tp 1 3 COMPLETETHEFOLLOWINGPROPERTY OWNER INFORMATION: n CHEOCIF OWNER Cl/RREN7LYONFREWITH EHD PROPERTY OWNER NAME � � —7 �n�� PHONE ' First Mt 'V` Last BUSINESS NAME )r�� /�z� SOC SEC/TAX ID# Owner Home Address �ij�� / /7 49A 1 ( ` /47 t /) � 95— DRIVER'S LICENSE# City 5�ciz-rD^J J(�/`T��/ ,I[� L✓</ (� STATE ZIP S / Owner Mailing Address 60"G Mailing Address City state Zip T VPF nF nWNFRGNTP t--� CORPORATION Q INDIVIDUAL❑ PARTNERSHIP❑ FED AGENCY❑ OTHER❑ FACILITY FILE FAatITY ID# oss REF ID# �I AccouNT ID# V� INV# t �^ MPLETF THE FOLLOWIN NFORMATION' 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/FACILITY/SITE NAME iI o r f/,"7/yf^ SITE ADDRESS / �/ _ SUITE# ��j BUSINESS PHONE CITY �A � STATE � Mailing Address ifDIFFERENTfrom FadlityAddress A Attention:or Care Of(optional) Mailing Address City STATE ZIP 1= THIRD PARTY BILLING INFO: Completed Billing Party is different from Property Owner or Facility Operator identifiedabove, BUSINESS NAM Attention:or Care Of (op#igna0 Mailing Address 3� /� PHONE;/f j_ /t CITY /'�. l� t/l�%1 STA /rte ZIP (�'W dC'r'wNrADDR"s fo—_rffees and charges OWNER FACILITY/BUSINESS THIRD PARTY BILLING Rn t t�'c tYD('o�lvt.tarcCF.aCxutw'i.t-nr.stF : 1,the undersigned Applicant,certify that I am the Oh-ner,Operator,or:luthoriced agent of this Business,and I acknowledge that all PE"ITFEES, PEV 1L"tTES,E,,VFORCEt1EMCFI IRGES and/or HOURI Y CHARGES associa led with this operation will be billed to me at the address identified above as the ACCOUYT:4 DDR PSS 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 COUNTY 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 HEAL'T'H DEPAR5as soon as.it"itr availabl and at the sam me it is provided to me or my representative. i "- PLEASE PRINTAPPLICANT NAME q SIGNATURE iV TITLE Z=4 DRIVER'S LICENSE# VI��'I,��-'•r (PHOTOCOPY REQUIRED) APPro,etf BY Date AmLting(Mice Processing Completed BY - Date 29-02-002 April 25,2003