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San Jo`-dquin County Environmental Health D;l. nent <br /> DAT -31 0 MASTER FILE RECORD INFORMATION "MFR" GREEN FORM <br /> SMMO Aa<•s FOR END onO OWNERID# CAE# UNIT IV <br /> OWNER FILE <br /> COMPLETE TNEFOLLOWING PROPERTY OWNER INFORMATTON., CREZXZP OWNER CURRENTIroar r ,vint EHD ❑ <br /> PROPINITY OWNER NAME <br /> PHONE ,, ,,r, <br /> First As Last �L <br /> BlI5INE55 NAME (j V T SOCSEc/Tex ID# <br /> Owner Horne Address � DRAIER's LICENA:# <br /> City STATE Rn <br /> Owner Mailing Address 1 I (tel] �. n u r•�s ,r`y�� <br /> Mailing Address City ��fl(/[�T t/f1��-(/f�'C•G Stam FA ZIP <br /> TYPEOPOw StsHlP <br /> CotmoeATloN ItmrviouaL❑ PARTNERsaP❑ FEoADDm❑ OrNER❑ <br /> FACILITY FILE <br /> FAatm ID# Cams ACcOUrrr ID# <br /> s REF ID# <br /> Comma ETNEFoLwwrw BUSINESS/FACILITY SITE INFORMATION: <br /> Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YEs ❑ No <br /> Is this an EIaSTING Business LOCATION but a NEW TYPE of regulated Business? YEs ❑ No <br /> BUsgiSS/FAt]I.IiY/SDE NAME <br /> Sm ADDays SUITE# Busuiess PHONE <br /> CM STATE ZIP <br /> BOAAD OF SUPEsty solr Dnaxtcr LocanON CODE KEYI KEY2 <br /> Ma I I i ng Address ifDIFFERENT horn Facaityrlddress Attention:or Care Of(optlonaf) <br /> Mailing Address City STATE ZIP <br /> SICCODE 11 APN# con,narr: <br /> THIRD PARTY BILLING INFO: Complete if Billing Party isdilirerentfrom Property Owner or Facility Operator idenbfiedabove. <br /> BustNESs NAME Attention:orCare1,Of (ophonaQ <br /> R <br /> Mailing Address rS1� PHONE . . 2-0-q9 <br /> cm ZIP <br /> FD VS YV, STATE <br /> AOfYlDAQ600aetT for fees and charges OWNER FACILITY/BUSINESS THI TY BILLING <br /> BILLING AND CO C¢ACKNOWLEDGMENT: 1,the undersigned Applicant;certify that I not the Dinner,OpemlOr,or Auraorlud Agent of this B.boan,and I acknowledge that all PAMIUT FEES, <br /> Pswtnrs,ENrvRC Citsecesaad/or Rourttr CIu Gc vanociatMwiththuoperadonwal6 biUedtomeattheaddressid.Iffedabavessthe ACVOu Amxrss for this site I also certify that all <br /> informafion provided on,this application is Ime,and corrmG vad that all regulated activities will be performed in accordance with all applicable SAN 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 resulte and environmental assessment information to SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT a jeon <br /> 'able aM at the same fime it ls <br /> provided tome or myrepreseohAtiva i= <br /> APPLICANT NAME PIFuePatNr SIGNANRE �agP,w <br /> TITLE DRrveR,�E# ARMDU' 'rAX 1D _ �}. 0343aa4 <br /> (PnOrocopc REQuTREo) <br /> Approved BY Date Manunting OIR®Prnnesaing Completed BY Date <br /> 29002 April 25,2003 <br />