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San Joaquin County Environmental Health Department <br /> DATE GREEN FORM <br /> "MASTER FILE RECORD INFORMATION "'MFR" <br /> SHwnFn encs Fru,can ISE ON OWNERID# � '- <br /> CSE# <br /> 6LJ00" UNIT I V <br /> OWNER <br /> FILE <br /> COMPLETE THE FOLLOWING PROPERTY OWNER INFORMATION,'_ LHEcKIF OWNER CuaRENTtroNFliewirH EHD 0 <br /> PROPERTY OWNER NAME 1197/e N,,,r I� C -::—i���7 PHONE <br /> / First Mf Last <br /> BUSINESS NAME /[ /�J d Q� '� i r—/r SOC SEC/TAx ID# <br /> Horne DRIVERS LICENSE# <br /> Owner Hoe Address ` So C2 / r �� J ' <br /> L <br /> Cl 4"A 1 rl K Ci R"c.,c.c' <br /> CIYy /e7 U Z J / G� STATE G A � 95357 <br /> Owner Mailing Address �7-SCJEY <br /> Mailing Address City 111-7-_Z7) 3 7U State (- Zip 95356- <br /> TYPFnFnwNFRcury <br /> �1 <br /> CORPORATION❑ INDIVIDUALL7 PARTNERSHIP❑ FED AGENCY El OTHER'D <br /> FACILITY FILE <br /> FACILITY ID# CROSS REF ID# ACCOUNT ID# INv# <br /> COMP0 5 2`l Zt' 32s��l <br /> LETS 7NEEMLOWZY6 BUSINESS I FACTI ITY I SITE NFoRmATI N' <br /> Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ No ®� <br /> Is this an ExISTING Business LOCATION but a NEW TYPE of regulated Business? YES ❑ No <br /> BUSINESS/FACILrrr/SITE NAME <br /> SITE ADDRESS %/'1 �-' SUITE# BUSINESS PHONE <br /> QTY /•�7,�...r C/a STATE ZIP J 3 6 <br /> BOARD OF SUPERvIsoR DISTRICT LOCATION CODE KEYS KEY2 <br /> Mailing Address ifnDIFFERENTfrom Faci/ityAdd�r+ess Attention:or Care Of(optional) <br /> L <br /> 3 J V�jtGc7.J j3 LV l� <br /> Mailing Address City`✓`j T �t•GSTATE <br /> ZIP <br /> SIC CODEAPN# COMMENT: <br /> THIRD PARTY BILLING INFO: Complete/f Billing Party is different from Property Owner c/-Facility Operator identified above. <br /> BUSINESS NAME Attention:oorCare Of (optional) <br /> (�✓A L:�s�G S �1/N s� 8! ��Sd._.Y,y i G�� �c.CIT. �7�,/-r S'.r/,'..c r�C�r' <br /> Mailing Address C ACOr LCL J� ? PHONE C�/6 j 7 -2 <br /> CITY F5 �,G.�.,o Pr{c a STATE (_T\ ZIP <br /> dr•rnrnvr dnnnFcc for fees and charges OWNER FACILITY/BUSINESS THIRD PARTY BILLING <br /> FUTITNQ AND C O.MPLIANCF.ACKNOWI.FMIMPNT; 1,the undersigned Applicant,certify that I am the 0"r,Operator,or Authorized Agent of this Business,and 1 acknowledge that all P£R$HT FEES. <br /> PENH.nKs,ENFORCEMENT CHARGES and/or 1I0URLY CHARGES associated with this operation will be billed tonic at the address identified above as the A CO avTAno F_ce for this site. I atio 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 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 <br /> any and all results and environmental assessment information to SAN JOAQUIN COUNTY ENN9RONNIENTAL HEALTH DEPARTMENT as soon as it is availob d at the same time it is <br /> provided to me or my representative. <br /> APPLICANT NAME PRINT SIGNATURE <br /> TITLE DRIVER'S LICENSE# <br /> �^ D/s /r �"�L✓G�Y� (PHOTOCOPY REQUIRED) <br /> Approved By Date Accounting Office Processing Completed By Date <br /> 29-02-002 April 25,2003 <br />