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San quin County En -ironmental Heal- epartment <br /> GREEN FORM <br /> DATE l 3 I O� MASTER FILE RECORD INFORMATION "MFR" <br /> OWNER ID# # UNIT IV <br /> OWNER FILE /��� <br /> COMPL PHOETHEFOLLOWINGPROPERTY OWNER INFORMATION; ar.FCHO NE OWNER CuRREivrzroMFr[FwrrHEHD El <br /> PROPERTY WNER <br /> NAE 4-0v) tf%r3� <br /> First MI las <br /> ll <br /> BUSINESS NAME \ 1 /I O✓ SOc SEC/TAX ID# O q_d / D V(,V <br /> /t <br /> Owner Home Address \7 'I ►/d CIS DRIVER'S LICENSE# <br /> City l.N I .� M STA ZIP 6 1 8 8 ?-164 <br /> Owner Mailing Address <br /> Mailing Ad dress City - a O S-�-a�, k- b✓� Stage <br /> C— Zip S 1 <br /> TYDF nF nWNFRGHTD <br /> ('noonoenn Tunnrtn�lei 1 1 DARTNFDGHTD l l FLA Ar.FNrll l •, MFD I I <br /> Cern rn TA fbnec DLe Tn A I Amro Orr Tn it INV# <br /> INFORMATION: <br /> Is this a NEw Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ No <br /> Is this an E)aSTING Business LOCATION but a NEw TYPE of regulated Business 7 YES ❑ No ql <br /> BusmESS/FACILITY/SITE NAME <br /> CQ 601'L - 1 <br /> SITE ADDRESS SUITE# BUSINESS PHONE <br /> (Ian C �lor� <br /> CITY G I ��� STATE <br /> uP <br /> BoaRD or SuPErtvssoR DIsTRICrIL!`I I LOcATIoN CODE f ( KEYl I I KEY2 <br /> Mailing Address WDIFFERENT from Facility Address A do :or CareTl -c <br /> ow"-V) <br /> fy - \�6 (�j -f, -C r- /✓1 cJ <br /> Mailing Address City 1+ c- k N STC` �P r <br /> S� oo `7 <br /> SIC CODE APN# COMMEO r. <br /> THIRD PARTY BILLING INFO: Complete if Billing Party is different from Property Owner or Facility Operator identified above. <br /> BuslNEss NAME Attention:or Care Of (optional) <br /> Mailing Address PHONEFILE CU T �1 <br /> CITY STATE ZIP <br /> ACCOI/Am DDRESS for fees and charges OWNER FACILITY/BUSINESS THIRD PARTY BILLING <br /> RII I INC AND CO\IPI IANCF ACKNOK'I FDG\t.NT: 1,the undersigned Applicant.certify that 1 am the Owner,Operator,or Authorized Agent of this Business,and 1 acknowledge that all PER,WTFEEs, <br /> PE.VALTtES,E.VFORCE.StEhT CHARGES and/or HOFRLYCHARGES associated With this operation will be billed to me at the address identified above as the ACCnt"yTADDRF.CC for this site. I also certify that all <br /> information provided on this application is true and correct; and that all regulated activities will be performed in accordance with all applicable SA.N JOAQUIN COUrcrY 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,1 hereby authorize the release of <br /> any and all results and environmental assessment information to SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DVLIIENT as soon as it is av ilable and at the same time it is <br /> provided to me or my representative. <br /> PLEASE PRINT <br /> APPLICANT NAME r ✓� e— d c Q u SIGNATURE <br /> TITLE r� I ' V 1 G✓1 c r (Hf OTTOCOP VR'SREEOUIRCNSED, U D 19 l S <br /> Approved BY :.. Date ngCom BY <br /> Date <br />