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4 San JOuin County Environmental Health leartment <br /> GREEN FORM <br /> DATE MASTER FILE RECORD INFORMATION `P`MFRrr <br /> FMn,w=nx,v OWNER ID# l 1 -7 b CASE# UNIT IV <br /> OWNER FILE <br /> COMPLETE THE FOLLOWING PROPERTY OWNER INFORMATION; CNECA'IF OWNER Cuaaex roNFrzz fvJrN END El <br /> PROPERIVOWNERNAME PHONE <br /> First �j M, Last - 3;7BUsmEss NAME Ci` <br /> SocSEc/TAx ID# <br /> �r �e Addressj, z C�7/ _�l ) 3 �G DRrnx's LICENSE# <br /> City LiL /.I�oZ STATE up <br /> Owner Mailing Address <br /> Mailing Address City State Zip <br /> Ivmnrnavmeaesam <br /> CORPORATION❑ INDIVIDUAL❑ PARTNERSHIP❑ FED AGENCY❑ OHI <br /> FACILITY FILE <br /> FACILRY ID# C7 CRoss REE ID# AccounT ID# 3 DS/� INv# <br /> COMPLErE THE LL WIN I oil ATI N' b <br /> Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ No <br /> Is this an ExISfING Business LOCATION but a NEW TYPE of regulated BusinesJs? {YES/❑ No <br /> BUSENEss/FAaJrry/$R ^,u.ENAME S V /�%7Y'?"�/Ll�� sykj -,— T.Vr JC r57I'IL� <br /> Sm ADDRE55 't/- /�� ` <br /> � SUITE# BUSINESS PHONE70/ <br /> Cm -. r )L14 F,SC14 <br /> -Y STATE Zip / <br /> BOARD of SUPERv60R DTsrsacr LocATTcNCCODE KEYS KeY2 Q <br /> Mailing Address NDIFFERENTfm n Fad1ityAddress Attention:or Care Of(optional) t y <br /> Mailing Address City STATE ZIP <br /> SIC CODE ARM# COMMENT: <br /> THIRD PARTY BILLING INFO; Comp/ete if Billing Party is different from Property Owner or Facility Operator identified above. <br /> BVsTNESs NAME r Attention:orCare Of (opblanal) <br /> Mailing Address J?32- rL P ///�tt— PHONE z� ^ 7 � � <br /> 2 - 76- <br /> Cm IlLy G1 ff- t D77V STATE up .L> <br /> S <br /> for fees and charges OWNER FACILITY/BUSINESS THIRD PARTY BILLING <br /> RrruNn Avn rnum IANCE ArKNOWI FDGMFNT; I,the undersigned Applicant,certify that 1 am the Owner,Operator,or Authadced Agent of this Business,and 1 acknowledge that aR PERMIT FEES, <br /> PEywLncs,ENFORCENENTCr/AFGE and/or HOURLY CIL RGP associated with this operation will be billed tome at the address identified above as the ACCOyATAUDRFCf for this sne. I also certify that <br /> all information provided on this application is true and correct;and that all regulated aMivines will be performed in accordance with all applicable SAN JOAQUIN 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 ddress,I hereby authorize the release of <br /> any and all results and environmental assessment Information to SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon d is available and at the same it is <br /> provided to me or my representative. <br /> APPLICANT NAME ^ k 1/,j <br /> f/ WP� P/' 637 SIGNATURE <br /> TITLE / ' s DRIVER'S LICENSE# <br /> l./ (PHOMM"REOUIRED) <br /> Approved By Date Accounting Office Processing Completed By Data <br /> 29-02-002 Apn125,2003 <br /> SU 1 �G �0 I � `� <br />