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• San ,a-.Aquin County Environmental Health t,.partrf���� <br /> DATE MASTER FILE RECORD INFORMATION "MFR" <br /> FEB <br /> CHAnt'n ARFLC FAQ Ftan TISF r)NIV OWNER ID# CASE# IV <br /> t T- <br /> OWNER FILEpFf�l�1i���1`Ir�c <br /> COMPLETE THEFOLLOWING PROPERTY OWNER INFORMATION; CHEGKIF O NE � r EHD <br /> PROPERTY OWNER NAME <br /> PHONE 3 <br /> First /I n Ml �) Last <br /> BUSINEss NAME m'l t / _ / 'U S /I SOC SEC/TAx ID# <br /> Owner Home Address /3 0 S 4E• !J'//f t� /�AV�` / eT Lrr DRIVER'S LICENSE# <br /> city Z Oct C�v !,3-2, d STATE ZIP <br /> Owner Mailing Address 7 <br /> Mailing Address City �t State Zip <br /> Tviw ru;nwNFRWTp D <br /> CORPORATION❑ INDMDUAL❑ PARTNERSHIP❑ FED AGENCY❑ OTHERWr <br /> FACILITY FILE <br /> FACILITY ID# �(1 1`' 1�5 CROSS REF ID# CCOiTI;# INV# L <br /> 0+ �5:, <br /> MPLETETHEF LLOWING NFORMATI N' <br /> Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ No ❑ <br /> Is this an E)QSTING Business LOCATION but a NEW TYPEofregulated Business? / YES ❑ No ❑ <br /> BUSINEss/FACILITY/SITE NAME ro o5 p,Q PO� 'E'( ,l f, 5C'L._. <br /> $ITEADDRESS �V 1!✓��L6C'C M I rtL 5C'4'Cy( <br /> SUS# BUSINESS PHONE ((-1 <br /> CITY kc <br /> STATE q ZIP <br /> BOARD OF SUPERVLSOR DISTRICT LOCATION CODE KEY1 KEY2 <br /> Mailing Address ifDIFFERENTfrom Fad/ityAdd�7ress t Attention:or Care Of(optional) I <br /> Mailing Address City STA ZIP <br /> FIC CODE F E <br /> COMMENT; —�\V <br /> THIRD PARTY BILLING INFO: Completeif Billing Party is different from Property Owner or Facility Operator identified above, i <br /> BusmEss NAME Attention:orCare Of (optional) <br /> [Mailing Address <br /> JPHONE 3/ <br /> DJ `Y ( <br /> Cm STATE ZPr Sr') <br /> r7� <br /> drvnumr.[nnvccc for fees and charges <br /> OWNER FACILITY/BUSINESS THIRD PARTY BILLING <br /> utLTINc AN f Ovrt tatice AChNO\NT.RDGMENT: 1,the undersigned Applicant,certify,that 1 am the Owner,Operator,or Authorised Agent of this Business,and I acknowledge that all PER31IT FEES, <br /> PENAL77ES,ENFORCEMENTCHARGEs and/or HOURLYCIIARGES associated with this operation will be billed to me at the address identified above as the ACCOLNTADDRFC,C for this site. 1 also certify that <br /> all information provided on this application is true and correct;and that all regulated activities will be perforated in accordance with all applicable SA.N JOAQL'IN COUNTY Ordinance Codes and/or <br /> 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,I hereby authorize the release of <br /> any and all results and environmental assessment information to SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH D RT\IENT as 700 ,11 it is available and at2sa time it is <br /> provided to me or my representative. ' <br /> APPLICANT NAME <br /> Do <br /> vi W(�Cl7 SIGNATUREr ✓ ri X, <br /> (J v v <br /> TITLE DRIVERS LICENSE# <br /> (PHOTOCOPY REOUIRED) <br /> Approved By Date Accounting Office Processing Completed By Date <br /> 29-02-002 April 25,2003 <br />