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San -iquin County Environmental Heal-" Department <br /> GREEN FORM <br /> 'DATE MASTER FILE RECORD INFORMATION ""MFR" <br /> FHn---rl,. OWNER ID# CASE# UNIT IV <br /> OWNER FILE <br /> COMPL ETE THE FOL L 0 WING P R 0 P E RTY OWNER INFORMATION: CHECKIF OWNER CURRENrcvoNF.TLEwrrHEHD <br /> PROPERTY OWNER \. PHONE <br /> NAME i` I� �tY�. -{ry r.� 7_0�)(4 <br /> J n!� Fire MI last <br /> BUSINESS NAME -)1 ^n / Soc SEc/TAx ID# <br /> Owner Home Address ' �` l DRIVER'S LicENSE# <br /> city C I V r�;.J�(, STATE ZIP <br /> Owner Mailing Address (-j <br /> Mailing Address City State Tzip <br /> TYPE TIF nwNFRGHTV <br /> rnD D(1D ATTlfN <br /> F1 TMn Mr\IlLl D.IDTNFD4ITP I I CFn rI PFNrII I rYTHFD 1 I <br /> FACILITY ID# - _ '- CROSS REF ID# ACCOUNT ID# INV# <br /> COMPLETE THEFOLLOWING BUSINESS I FACIL I SITE INFORMA TI 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 Q. No ❑ <br /> BUSINESS/FACILITY/SITE NAME - <br /> l <br /> lC (7 �r <br /> SITE ADDRESS �,^ �� _ SUITE# BUSINESS PHONE <br /> Cm �+ 1 + I r--_ `/ STATE ZIP <br /> IIBOARD OF SUPERVISOR DISTRICT I I LOCATION CODE I KEY1 I I KEYZ I (I <br /> Mailing Address if DIFFERENT from Facility Address Attention:or Care Of(optional) <br /> Mailing Address City STATE uP <br /> llSIC CODE APN# COMMENT: <br /> THIRD PARTY BILLING INFO: Comp/ete if Billing Party is different from Property Owner or Facility Operator identified above. <br /> BUSINESS NAMEA ention: rCare Of (optional) <br /> Mailing AddressP.^^ N L . <br /> CIT'' ' .. - "(+"/�' �V�`� STATE ZIP <br /> drrnrrtvrdnncccc for fees and charges OWNER FACILITY/BUSINESS THIRD PARTY BILLING <br /> BU t INC •tin('nvtat i vvcF AC9CNt1Wt_FD(:\IPNT: 1,the undersigned Applicant,certify that I am the Owner,Operator,or Authorized Agent of this Business,and I acknowledge that all PERMIT FEES, <br /> PENALT1Es,E.YFORCE,HE.YrCHARGE$and/or HOURLYCHARGES associated with this operation will be billed to me at the address identified above as the 4CCO11VT ADDRFCS for this site. 1 also certify that all <br /> information provided on this application is true and correct;and that all regulated activities will be performed in accordance with all applicable SA,Y 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,I hereby authorize the release of <br /> 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 <br /> provided to me or my representative. <br /> PLEASE PRINT l <br /> APPLICANT NAM �._� Lti��o ��k'.% / SIGNATURE <br /> TITLE DRIVER'S LICENSE# <br /> (PHOTOCOPY REQUIRED) <br /> Approved By Date Accounting Office Processing Completed By Date <br />