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CONFIDENTIAL <br /> 1 <br /> San Joaquin County Environmental Heal <br /> q ty Health Department e} <br /> DATE X03 MASTER FILE RECORD INFORMATION "MFR" GREEN FORM <br /> oFHfI� cllx OWNER ID# vol.0 - q I <br /> CASE# UNIT IV <br /> OVMER FILE <br /> COMPLETE THEFOLLOWING PROPERTY OWNER INFORMATION; CHECKIF OWNER CURRENTLYONFYLE Wrm EHD <br /> PROPERTY OWNER PHONE / <br /> NAME 11 ?c>q — 83(. <br /> First Ml last 11 <br /> OS % <br /> BUSINEss NAME SOC SEC/TAx ID# <br /> c— /51/cw <br /> Owner Home[ ddressfJ(� %�(� r /`/ / DRIVER'S LICENSE# <br /> _ d <br /> city STATE"/J ZIP 95-37(0 <br /> Owner Malllttp Address T <br /> Mailing Ailaress Cjt E / G state n./7 GJ Zip ?.—T 7 b <br /> 1 l <br /> TVPf=nF(7WNrRsHTP (*) <br /> ('llp0llp ATlllN rNrlTvrn11A1 1 DApTNFp CHTD 1 I FFII Ar_FNry F� (ITHFp <br /> rAtll 1=Fill F: <br /> FACILITY ID# t)1 4 f 1 "7 CRoss REF ID# ACCOUNT ID# A ri✓?(i>/ INV# <br /> COMPLETE THEFOLL WING BUSINESS I FArT1 TTY I SITE NF RMATI 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/FACILITY/$ITE NAME L_M [� / / / ,/ �/'f� i/IJ/ i rl OK✓f 'AliN Owde <br /> SITE ADDRESS SUITE# BUSINESS PHONE <br /> �� o7D�' -- vr'L> -off <br /> CITY — <br /> STATE ZIP <br /> BOARD OF SUPERVISOR DISTRICT I I LOCATION CODE I I KEYI I. ( KEY2 <br /> Mailing Address ifDIFFERENTfrom FacilityAddness Attention:or Care Of(optional) <br /> 3 !�(� j Y�c, 191yc� <br /> Mailing Address City STATE ZI <br /> SIC CODE APN# CDMMENT <br /> THIRD PARTY BILLING INFO: Complete if Billing Party is different from Property Owner or Facility Operator identified above. <br /> BUSINESS NAME Attention:or Care Of (optional) <br /> Mailing Address PHONE <br /> Cm' STATE Zip <br /> dr-rntlur dnnOFQC for fees and charges OWNER FACILITY/BUSINESS THIRD PARTY BILLING <br /> Rn.t.rvr.:�un('nnu�t taucF.ncx�Owt FnentF'1T: 1,the undersigned Applicant,certify that 1 am the Owner,Operator,or Authorized Agent of this Business,and I acknowledge that all PERMIT FEES, <br /> PENALTIES,ENFORCT:HEYT CHARGES a., HOURLI'CHARGES associated with this operation will be billed to me at the address identified above as the AccotcyT-tnnRFeS for this site. I also certify that <br /> all information provided on this application is true and correct:and that allregulated activities will be performed in accordance with all applicable SAN JOAQU'IN COUNIy Ordinance Codes and/or <br /> Standards and STATE and/or FEDERAi,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 DEPARTNIEN'T. so n as it is available and at the same time it is <br /> provided to me or my representative. <br /> �TT <br /> n_ l PLEASE PRINT <br /> APPLICANT NAME . rvl K PL 00 SIGNATURE Px <br /> ` <br /> TITLE (PHODRI`TOCOPY RE ER'S LICEUIIRED) ! ���/ <br /> Approved By G" Date Accounting Office Processing Completed BY Zr � Date fO <br /> ( -b�� P6,-)k- 1 IAIONLU � <br />