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� I Sar, aquin County Environmental Healt. apartment DATE MASTER FILE RECORD INFORMATION "MFR" GREEN FORM SHADED AREAS FOR EHD U8E0111Y OWNER ID# �oD I �3Q% CASE# UNIT IV OVMER FILE COMPLETE THEFOLLOWING PROPERTY OWNER/NFORMAT/ON. CNecxiF OWNER CVRRENnYONRLEWmH EHD PROPERTY OWNER NAME Q� YYl L.� 6.YA PHONE ZDLq Cv S— First Ml Last CJ BUSINESS NAME SOC SEC/TAX ID# Owner Home Address i j SQ O O G k�YA DRrvER's LICENSE# City / n STATE C6ZIP Owner Melling Address Melling Address City tF1 r��_ Stats�j Mp G� , l"� CORPORATION❑ INDIVIDUAL❑ PARTNERSHIP❑ FED AOENcY❑ OTHER❑ FACILITY FILE FACILITY ID# CROSS REF ID# AccouNT ID# l"IZ- CONK ETETHEFOL LOW/NG BUSINESS/FACILITY/SITE/NFORMAT(ON.' 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 ❑ BUSINEsefFACILITY/SITE NAME �.� _ G"-, lQ �\ 1\� [_ SITE ADDRESS 7 y D N ^• a I,)I ��Y,e� v` SUITE# BUSINESS PHONE CITY `„ J e r r-- STATEC,,q ZIP [BOARD OF SUPERVISOR DISTRICT C' LOCATION CODE KEY'I KEY2 Mailing Address KD/FFERENTfrornFac//kyAddiess 'S-500 K kl,j ;f JAVt_• Attenllon:or CareOF(opolone/J Mailing Address City[SIC —G Irt+hy(� C- STATE('' ' ICODE L APN# COMMENT: v THIRD PARTY BILLING INFO: Complete ifBilling Party is different from Property Owner orFacility Operator identified above. BUSINESS NAME k le i vt f e l e-r Attention:orCareOF(op&bm/) `T.�� Z-11-es 1 1-es Melling Address �a t Arc► 1 1 \I(� 9')(� 1 S(/�I �� lQ� PHONE �6—ter: 1 v —` 7l Cm }- \��il✓1 STATE /T ZIPt' J/^ Acc=m`AD`D'IREw for fees and charges OWNER FACILITY/BUSINESS ` THIRD PARTY BILLING2 IIJJ BILLING AND COMPLIANCE ACKNOWLEDGMENT: 1,the undersigned Applicant.certify that I am the Owner.Operator,or Authorized Agent of this Business,and I acknowledge that all PER.vrrFEEs, PEAALTms.ENFORCEMENT CHARGES and/or Hot:RLY CHARGES associated with this operation will be billed to me at the address identified above as the ACCOL:NTADDRESS for this site. I also certify 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 COUNT'Ordinance Codes and/or 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 any and all results and environmental assessment information to SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. APPLICANT NAME PLEASE PRINT, SIGNATURE TITLE G �P•„� P�.- DRIVER'S LICEN # _jPHOTOCOPY R IRED Approved BY Date Accounting Office Processing Completed By Date 29-02 10/12/07 MASTER FlLt RECORD-GREEN