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San Joaquin County Environmental Healt" t DATE 9MASTER FILE RECORD INFORMATION "MFWP 3 O 2008 GREEN FORM SHADED AREAS FOR EHDUSE ONLY OWNER ID# OWtjN k2 RD1 CASE ENVIRGNME T HEAUNIT IV OVMER FILE COMPLETE THEFOLLOWING PROPERTY OWNER/NFORMAT/ON. CHEcK/F OWNER CURRENTLYoNFILEwrH EHD PROPERTY OWNER NAME ^� •"l A LOLY ,)�S G PHONE Q 2 �c- 2'I- 23`1 S First M/ Last BUSINESS NAME v kCA,``; Q� _\ •��\ V ON�� SOC SEC 1TAX ID# ✓C 5 r�Q'1 Owner Home Address 1?1.13C` `� \ �� A DRIVER'S LICENSE# 'P O'k(O 4 E>O ' City oc�l G \ V`J SATEC ZIP C�2 L Z Owner Mailing Address ✓ Mailing Address City Siete Ekz!P 2- Z CORPORATION ElINDIVIDUALS PARTNERSHIP❑ FED AGENCY❑ OTHER❑ FACILITY FILE FACILITY ID# 4 � CROSS REF ID# ACCOUNT IO# (��(/�\ (�] �a aw,13, 2,1 1 INV# 1 Vim/3 1 COMPLETE THEFOLLOW/NG BUSI NESS/FACI LITY/SITE/NFORMAT/ON.' �J `` `1 IS this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPT.? YES ❑ No 1K IS this an EXISTING Business LOCATION but a NEW TYPE Of regulated Business? ��t `YES ❑ No A BUSINESSIFACILRYISITE NAME Fc)-v-vi�-v 1.....p a•t. SITE ADDRESS /_ L 1 QY \ ` A_ \� r7 I _ . SUITE# BUSINESSPHONE Nvv� CITY r Q CUL STATE CA /� zip BOARD OF SUPERVISOR DISTRICT 6 4' LOCATION CODE O 2 KEY1 KEY2 `•/'l Mailing Address ifD/FFERENT from FV acilliyAddress Attention:or Care Of(optional) 1 1 ' ^ �o� 1tija--'rSS0Vt Mailing Address City , 3 ) b �V I L,,4C:> STATE CA ZIP 9 C�q SIC CODE APN# COMMENT: 1 THIRD PARTY BILLING INFO: CompleteifBilling Party is different from Property Owner or Facility Operator identified above. BUSINESS NAME \ Attention:orCare Of(opbbnal) Mailing Address S S ✓Vl ON4 v � PHONE LA OceO — a9 Cm C C>,-V\.-V\. C JC=p� STATE zip AccoueTADDREw for fees and charges OWNER FACILITY/BUSINESS THIRD PARTY BILLING BILLING AND COMPLI.ANcE ACKNOWLEDGMENT: ],the undersigned Applicant,certify that I am the(honer,Operator,or Authorized-lgent of this Business,and I acknowledge that all PERMIT FEES', PENA1.77Es,ENFORCEMENTCHARGES and/or HOURLYCHARG'ES associated with this operation will be billed tome at the address identified above as the AC('O(.,y7'ADORF.,SS for this site. 1 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 COUNTY 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 p y�Y �p�1 � SIGNATURE TITLE �Y ot-QSS 1oti�� rcO)prjl s} /�Yo�eLtN�IedVORIVER'SLICENSE# O 1 b Lt p s J / J (PHOTOCOPY REQUIRED) 'T A roved B PP Y Date � G 6 0 Accounting Office Processing Completed By �" Date \� v 29-02 10/12/07 .MAS LR FJLERECORD-GREEN