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San Joaquin County Environmental Health Department GREEN FORM DATE MASTER FILE RECORD INFORMATION ""MFR" GHAnFn ARFAG FnR FHn IICF nNl Y �wUNIT IV OWNER FILE !�. COMPLETE THE FOLLOWING PROPERTY OWNER INFORMATION; OifcKIF OWNER CURRENTLYONFILEwzrH EHD PROPERTY OWNER NAME /�//t T A PHONE First Ml Last BUSINESS NAME SOC SEc/TAX ID# Owner Home Address DRIVER'S LICENSE# city STATE zip Owner Mailing Address 1 i t v� Mailing Address City moi/ 1J State Zip �� 3Y[M OF TTWNFRCHTR ( !/C�(f� CORPORATION❑ INDMDUAL PARTNERSHIP❑ FED AGENCY❑ OTHER❑ FACILITY FILE FACILITY ID# bD15�) CROSS REF ID# ACcOUNT ID# �LAP.2&5,95: INV# COMPLETE THEF LL 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 SITE ADDRESS F. / 1 10 5 �� SUITE# BUSI"�R 44 r CITY C /`J //F�Q.� STATE/ iA ZIP (752 0--� Mailing Address ifDIFFERENTf vm FaciGtyAddiess Attention:or Care Of(optional) Mailing Address City STATE ZIP THIRD PARTY BILLING INFO: Completeif Billing Party is different from Property Owner or Facility Operator identified above. BUSINESS NAME ,I Attention:orCare Of (optional) Address ` / / PHONEF (A-7M,ir,ngl� Cm //�ir/�q^ � f+ 7 STATEj� '7zIP"j/�Jr.Q��/ ACCOL uTA0090- for feesand rehharges �O OWNER FACILITY/BUSINESS THIRD PARTY BILLING Ru.+.+NC.ANn('on+rt�ANCF ACKN LLj G11FNT: 1,the undersigned Applicant,certify that 1 am the Owner,Operator,or Authorized Agent of this Business,and I acknowledge that all PERMIT FEES, PENALTTEB,BNFORCE,4IENTCIL4RGFS and/or HOURLYCHARGES associated with this operation will be billed to me at the address identified above as the ACCOLIT,4nORecc 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,1 hereby authorize the release of any and all results and environmental assessment information to SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time itis provided to me or my representative. PLEASE PRINT � APPLICANT NAME ,CY/ � A—�— SIGNATURE / TITLE X(�' /' DRIVER'S LICENSE OTOCOPY REQUIRED) Approved By Date Accounting Office Processing Completed By Date 29-02-002 April 25,2003 CONFIDENTIAL