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,wcc: —^re.*''cPxL°E �^cr,: - c ^. •y .-r, -I .,s,:z„r!e'�,:mz "+sr ' 'F `s'' � `� <br /> San: qIrCetitalFeaitii <br /> DATE 712-6 � <br /> ' Z MASTER FILE RECORD INFORMATiON '%%MFRGREEN FORMUNIT IV <br /> SnnolQaauas to Dusl_(Llr s OWNER ID.7F�. r � <br /> OWNER FILE <br /> COMPLETE THEFOLLOWING PROPERTY OWNER INFORMATION: CHECXIF OWNER CuRRENrzroNFnEwrTHEHD ❑ <br /> r <br /> PROPERTY OWNER \ - PHONE 5 3 0\ 75(o <br /> (6 — 1�)j, <br /> Z ' 9p <br /> NAME \` J ) V <br /> Fcsf MI . last • <br /> BUSING NAI"IE • I SOC SEC/TAX ID# <br /> L avis' I <br /> Owner Home!Address 1 DRIVER'S LICENSE# <br /> 1Y• <br /> City I STATFC ZIP q 5 I !o <br /> Owner Mailing Address <br /> ...aA Wa► Q <br /> Mailing Address City state I <br /> Zip <br /> Type OF OWNERSHIP <br /> CORPORATION❑ INDIVIDUAL❑ PARTNERSHIP❑ FED AGENCY❑ OTHER❑ <br /> FACILITY FILE <br /> a <br /> } t <br /> `PACILITr, 6 -k"xe <br /> ) I <br /> ,�CAIPLETETHE FOLLOWING BUSINESS FACILITY/ SITE INFOR.+fATION. <br /> Is this a NEw Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ No ❑ <br /> Is this an EXISTING Business LOc1TION but a NEw TYPE of regulated Business? YES ❑ No ❑ <br /> BUSINESS FAQLITv/SITE NAME <br /> Hof,VV t.Y `.o8;i btxaQJ <br /> SITE ADDRESS SUITE# BUSINESS PHpNE <br /> 2 West L_ockeZojr� S} AIA <br /> c.`TY L Oa' STATEC x ZIP <br /> � ;,F a� s ,znrw�k ��rt "" �� _ "aaa rarY –_:,, ✓Tl <br /> BOARD OFSUPFRVISOR�I�LSIRICTt-. <br /> L r rte,Efts, <br /> Mailing Address ifDIFFERENTfiomFadlityAddress Attention:or Care Of(optional) <br /> Mailing Address City STATE ZIP <br /> rY , .x�,:. JI;t,':+�. _ . ?i.. M�4 r�"`L„X�x .�'''�,,� �Y•'i '��I-'� s1y�31'- it ' kre ,.''��. .f. G:`. <br /> THIRD PARTY BILLING INFO: Complete If Billing Party is different from Property Owner or Facility Operator identified above. <br /> BUSINESS NAME Attention:or Care Of (optional, <br /> q-ie-1 rvck. vi w�ev�� ' Cl <br /> Mailing Address `✓O 75 PHONE Og ^ <br /> y q 3 - 0i83 <br /> CITY �+�1 `.Y STATE ^A ZIP K237 <br /> 7 <br /> AL'.QULYT_ADDRE55 for fees and charges OWNER FACILITY/BUSINESS THIRD PARTY BILLING <br /> ai <br /> BILLING.IND COnIPLIANCE ACKNOWLEDCMENT: 1,the undersigned Applicant,certify that I am the Owner,Operator,or Authorized Agent of this Business,and I acknowledge that all PF.RM11,FFFS, <br /> PEN.7 L.'78T,FNFIIRCFA/F.NTCH:646F4 and/or fIOURLT CILtRGFS associated with this operation will be billed to me at the address identified above as the ACCOUNTAUDRFSS for this site. I also certify that <br /> 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 <br /> Standards,md STATE and/or FEDERAL Laws and Regulations. As the undersigned owner,operator,or agent of the property located at the abnve facility/site address,I hereby authorize the release of <br /> any and Al resuits and environmental assessment information to SAN JOAQUIN COUNTY ENVIRONMENTAL IIEALTN DEPARTMENr as soon as it is available and at the same time it is <br /> provided to me or my representative. <br /> PLEASE PRINT <br /> APPLICANT NAME N,\ Q ' I/ aCr� SIGNATURE <br /> TITLE ',e�W �� Vid LAK) DRIVER'S "NSE# <br /> v (PHOTO Y REQUIR1333 <br /> Approved;ay�,, ACCOunAing,Office Processing.Completed By;". <br /> ? } <br />