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San Joaquin County Environmental Health Department GREEN FORM DATE (/f MASTER FILE RECORD INFORMATION "MFR if CHenM ARFAQ Fno FHn ncF nN1 v 63-7S— 3-7 — " UNIT '((((//// OWNER FILE r COMPLETETHEFOLLOWMGPROPERTY OWNER INFORMATION; CNECKIF OWNER CURREN7LYONFIIEwn7i EHD PROPERTY OWNER NAME iy1.F.I� ✓1/I?/1.n J/ PHONE Q C n \ © tFirst Mt Lasst BUSINESS NAME l SOC SEC/TAX ID#' � T � i� Owner Home Address boy - ' DRrvEWS LJcENsE# /fI � ^en 3 city CA q5 3 71 STATE / ZIP c7 r3 Owner Mailing Address Mailing Address City '/tState Zip F nc nuu Fga;Hro CORPORATION❑ INDIVIDUAL PARTNERSHIP❑ FED AGENCY❑ OTHER❑ FACILITY FILE FAaLm ID# 1 �i t G" CROSS REFID# 11 ACMUNT ID# f t[t �3 INV# 1 5'-2 i C� COMPLETE7NEFOILOMWGQ M TI w l — IS this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES NO ❑ Is this an E)asTING Business LOCATION but a NEw TYPE of regulated Business? YES ❑ No BUSWESs/FAaLnY/SITE NAME SITE ADDRESS 7- A I/] �y-t• 1 ,�n,�J�l' ! / SUITE# BUSINESS PHONE'------- Cm I L'[il 7�Jl/�rfJ��J S7ATE[�/!`I' � / E:: Mailing Address WDIFFER�from Fav/ityAddrets Attention: or Care Of(op L Zai iq�y Mailing Address City STATE ZIP -� 7rC� p� SCSIL ' Q3©qo27 THIRD PARTY BILLING INFO: Complete if Billing Party is dilferentfmm Property Owner or Facility Operator identified above. BUSINESS NAME Attention:or Care Of (optional) Mailing Address PHONE CITY STATE ZIP for fees and charges OWNER FACILITY/BUSINESS THIRD PARTY BILLING RiLt.tNG Ann CoMP1.lANrR A zublia.EnpMFNT, I,the undersigned Appticaw,certify that I am the Owner,Operator,or Authorized Agent of this Business,and I acknowledge that all PE TFEES, PHNAIMES,ENFORCEMENTCXARCES and/Or HOURLYCIMRGES associated with this operation will be billed to me at the address identified above as the ArrOfATAnDRF.C.0 for this site. 1 also tify that all information provided on this application is true and correct;and tha:all regulated activities will be performed in accordance with all applies JANdOAQ; N- rdinance C and/or Standards and STATE and/or FEDERAL Laws and Regulations.As the undersigned owner,operator,or agent of the property located at thgab6ve facility/site address,I hereby authon elease of any and all results and environmental assessment information to SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH D T DENT as soon as it is available and at the an t 't is provided to me or my representative. APPLICANT NAME A d 7/ �AA; T SIGNAL E TITLE rT�ll F DRIVER'S LLE SIJ fPFiOTOCOPY EDI Approved By Date A=unting Office Processing completed By Date G' 73 29-02-002 April 25,2003