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San Juin County Environmental Health )artment GREEN FORM DATE MASTER FILE RECORD INFORMATION "MFR" CNAnFn AaFAC FOR FHn IICF TINT V OWNER ID# 112-q CASE# UNIT IV OWNER FILE COMPLETE THE FOLLOWING PROPERTY OWNER INFORMA770N; CHECKIF OWNER CuaREVTLYoNFrLEwrrH EHD PROPERTY OWNER44ANE G PHONE C1.i` 1k 8-!;,- 3 y g y !A-S P- First M/ Last BUSINESS NAME [) - SOC SEC/C-16 -ID 33 F o-319 t; 1 Owner Home Address () ��ts� DRIVER'S LICENSE# g (-5�g--?'I city STATE CA ZIP G.� lJ / tM �ffimgp`Address iling Address City State Zip CORPORATIO49- INDMDUAL❑ PARTNERSHIP❑ FED AGENCY❑ OTHER❑ FACILITY FILE FACILITY ID# / /II�7 C CROSS REF ID# :jAccouNT ID#.- INV# C014PLETETHEFOLLOWING BUSINESS I FACILITY I SITE INFOR.4fwyom' Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ No Is this an EXIMNG Business LOCATION but a NEW TYPE of regulated Business? YES ❑ No BusmEss/FAmm/SIrE NAME SITE ADDRESSI .L G L L� I� (/ SUITE# B l ESS S'2-3 NE — !W-1 17 \ CITY t-n_+ CA-STATE ZIP cl S-3 3 6 W�'^ BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEYL KEY2 Mailing Address rfDIFFERENTfrom FadlityAddress Attention:or Care Of(optional) ^ Mailing Address City STATE ZIP n SIC CODE AP # COMMENT: J THIRD PARTY BILLING INPO, Complete if Billing Party is different from Property Owner or Facility Operator identified above. BUSINESS NAME + Attention:or Care Of(opdonall ^ /t� �.-tR �Nv LIZ, +,_ r ( �t Mailing Address I`C� C t�2 o l� 4 l 20 u ck -1 51>3 PHONE Cl I G -�L 2� - C) f1L CITY l� STATE IIP e M/f1=40ngFCC for fees and charges OWNER FACILITY/BUSINESS THIRD PARTY BILLING Rif r nuo a mn rimpi 1!N!F Ar ieNniyi FnCMFNT' 1,the undersigned Applicant.certify that-!am the Owner,Operator,or Authorized Agent of this Business,and I aclutowledge that all PERMIT FEES, PENALTIES,ENFORCEMENT CHARGES and/or HouRLYCHARGES associated with this operation will be billed to me at the address identified above as the ACMINT 4nnRFFC for this site. 1 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 JOAQULN COUNT-1 Ordinance Codes and/or Standards and STATE and/or FEDERAL Laws and Regulations. As the undersigned owner,operator,or agent of the proper[)located at the above facility/site address,1 hereby authorize the release of any and all results and environmental assessment information to SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPA TMENT as soon�is available and at the same time it is provided to me or my representative. pLFASEPRINTAPPLICANl� R�i,TNAME � lr 1 �� SIGNATUREa� TITLE r ( `S 1 (PHOTOCOPY REQUIRED) Z� �p Approved By Date Accounting Office Processing Completed By Date 29-02-002 April 25,2003 CONFIDENTIAL