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San Joaauin County Environmental Health f artment DATE 2 . 7-1- OS, MAS i ER FILE RECORD INFORMATION "MFR" GREEN FORM $HHADEO AREAS FOR EHD USE ONLYOWNER ID# L nn C Q CASE# UNIT IV Ov J \� i OWNER FILE COMPLETETHEFOLLowINGPROPERTY OWNER INFORMATION. --CHECKIF OWNER CURRENTLYONFILEWITN EHD PROPERTY OWNER NAME a- ✓Z PHONE d _ 3II g „ 2--41 r ^ First Mf Last j BUSINESS NAME —Tl,v S Q SOC SEC/TAx ID# Owner Home Address 4 3_3 r l DRIVER'S LICENSE# City co '1' STAT ZIP Owner Mailing Address Mailing Address City qG � State ZIP TYP 1;111"YIN r RR 11111 CORPORATION❑ INDIVIDUAL❑ PARTNERSHIP❑ FED AGENCY❑ OTHER FACILITY FILE FACILITY ID# / CROSS REF ID# 7=:]LACCOUNTID# \ C C INV# COMPLETE THEFOLLowlNG BUSINESS FACILITY t SITE INFORMATION. S Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPT.? YES ❑ NO IS this an EXISTING Business LOCATION but a NEW TYPE Of regulated Business? YES ❑ NO BUSINESS/FACILITYISITE NAME SITEADORESS 1` SUITE# BUSINESS PHONE CITU S TAE zip S BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEY1 !j KEY2 Mailing Address lfDIFFERENTfrom Fac/I/tyAddress Attention:or Care Of(optional) Mailing Address City STATE ZIP SICCODE APN# COMMENT: THIRD PARTY BILLING INFO: Complete ifBilling Party is different from Property Owner or Facility Operator identified above. BUSINESS NAMEC Attention:orCare Of (000-9J G V1.S14-- c C " ( C �t r... ^ Mailing Address 1575-15- 5-1 1,/ t t 6 �^ PHONE 1J O G„ /L�".r CITY Lo" G Z (a•�'TA STATE �[4 G ZJP J WS-O 3 C AccoujivrADDREss for fees and charges OWNER FACILITY/BUSINESS THIRD PARTY BILLING 1311.t.INC.ANI)COMPLIANCE ACKNOWLEtGMFN9': 1,the undet signed Applicant,certify that Ian)the(honer,Operator,or Authorized Agent of this Business,and I acknowledge that all PliRatil hill>5', PENAL T/E1',EAWOR'EMEWI CLt IGEN and/or 110VItLY CnAlwi V associated with this operation will be billed to me al the address identified above as the A(coUN7 ADPRFC4 for Ihls Site. I also Cel'tlfy 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 COUNr1'Ordinance Codes and/or Standards and STATR.and/or PEUER U.Laws and Regulations. As the undersigned owner,operator,or agent of the property located at the above facilitylsite address,I hereby authorize the release of in),and all results and environmental assessment information to SAN JOAQUIN COUNTY ENVIRONNIEN'rAl,HEALTH DEPARTMEN'r as soon as it is available and at the same time it is provided to me or my representative. APPLICANT NAME , PLEA$E PRIN SIGNATURE I- TITLE DRIVER'S LICENSE# �✓�b}� _ t, C t('t � (PHOTOCOPY REQUIRED) e I+�-( r Approved By ` C^1 Date Accounting Office Processing Completed By 0 ` O