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San Joaquin County Environmental Health Department GREEN FORM <br /> DATEMASTER FILE RECORD INFORMATION "'MFR" D11G 2 3 ZOQZ <br /> EEEEL <br /> F— w v <br /> OWNERID# T?P)l33 CASE# <br /> LUNIT 1V i�-, <br /> OWNER FILE <br /> CNECK IF OWNER CURRENTLYON FILf WITHEHD <br /> COMPLETE THE FOLLOWING PROPERTY OWNER INFORMATION; <br /> PHONE <br /> PROPERTY OWNER <br /> B <br /> ��] <br /> NAME r <br /> Fusf <br /> hll !ast <br /> SOC SEC/TAx ID# <br /> BUSINESS NAME f <br /> liL DRIVERS LICENSE# <br /> Owner Home Address <br /> STATE ZIP <br /> City (� / <br /> Owner Mailing Address 1 /1(� 7 T y �0 oo <br /> State60 Zip <br /> �o-1'� / <br /> Mailing Address City <br /> pF fLF rIVJNLRCHTp r nT.-11TAd%11 Ilry Fill F: <br /> I._I <br /> rrlp dlp eTlrlN <br /> Trinnrtro�e� l__I DepTNLp WTp❑ <br /> �— INV# <br /> FACILITY ID# <br /> Dl Z CROSS REF ID# ACCOUNT ID# <br /> Nf 2RMAI TI aN'rr) \ L <br /> � <br /> MP ETE HE F WN YES [:1No� <br /> Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? <br /> YES ❑ No <br /> Is Lf is an EXISTING Business LOCATION but a NEW TYPE of regulated Business <br /> BUSINESS/FACILITY/SITE NAME Cf I n inti <br /> {I-'/� SUITE# BU ESS PHONE <br /> SITE ADDRESS /1� S 1NLq ^ l <br /> (0(J �C[� Lx� / 1 STATE ZIP <br /> CITY <br /> L/t I I I �1 I I KEY2 I II <br /> II BOARD OF SUPERVISOR DISTRICT I LOCATION CODE <br /> Attention:or Care Of(option:) <br /> Mailing Address ifDIFFERENTfrom Facility Address <br /> STATE ZIP <br /> Mailing Address City <br /> SIC CODE <br /> APN# COMMENT: <br /> THIRD PARTY BILLING INFO; Completed Billing Party is different from Property Owner or Facility Operator identified a ove. <br /> e ✓ _ _ Attenti :orCare Of (optional) n� <br /> BUSINESS NAME <br /> I /\/ i–, i PHONE <br /> Fling Address I0-D STATE lI Lnzip P l0�sebI <br /> CmQ—CkV/-til D <br /> r <br /> errnriA,+AD W.W for fees and charges OWNER FACILITYi13Ll$aNEss <br /> THIRD PARTY BILLING � <br /> R l c 'D('01IP1 t•NTT `Ct:vUwl rDGxF1I: Applicantcertify that I am the O ner,Operator,or Authorized Age^!of tis$usmess,andl acknowledge that all PER.tt1T FEES, <br /> 1,the undersigned Athe <br /> PEN4LTIEs,ENFORCEA/ENT n A sES and/or <br /> application O true and correctsocia hatith thisregpevation ated activities will be ill be performed illed tome at in accordance ress with a 1 appl c bleaSAN JO.IQUIN CCOUNTY Ordinance Codes and/or <br /> all information provided o <br /> any anddall ressultsTand environmental Laws <br /> assessmentt information othe <br /> SANundersigned <br /> JOAQUIN COUNTY ENVIRONMENTALproperty <br /> HEALTHlocated <br /> DEPARTMENTf as soon as it iite address,available and aththe same time itorize the release is <br /> any <br /> provided to me or my representative. PLEASE PRINT <br /> 1 1 a r( V) S SIGNATU <br /> APPLICANT NAME 2 Lf <br /> J C <br /> S`�' 'J� DRIVER'S LIC SE# <br /> TITLE (PHOTOCOPY REO <br /> Approved By Date <br /> Accountings Processing Completed BY ,_,.,— Date "1. T <br />