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San ., .juin County Environmental Health, jartment GREEN FORM DATE ,- MASTER FILE RECORD INFORMATION "MFRY' Fi�w /N CIAO nFn ARFAC FnR FHn I1SE-OK y OWNER ID# 17 /L_JCASE# UNIT IV �i/ OWNER FILE COMPLETE THE FOLLOWING PROPERTY OWNER INFORMATION: CHECKIF OWNER CuRREtvrtroNFrtEJvzjrt E H D PROPERTY OWNER NAME Sa e— T Ma�a J First MI Last 1;E Lil BUSINESS NAMEJ G�`�, T ��Y- SOC SEC/TAx ID# Owner Home Address Zt,�—)�` ) / 5 �a�t L� DRIVER'S LICENSE# CRY ',2 STATE CFS ZSP 9153-2-7) Owner Mailing Address S aY � Mailing Address City State Zip TYPF nF nwNFRCHTR CORPORATION❑ INDIVIDUAL❑ PARTNERSHIP❑ FED AGENCY❑ OTHER N'TT FACILITY FILE ./� V �K-- ID# 1 =1'? Foss REF ID# ACCOUNT ID# J N 1r1 I _� INV# OMPLETE THE FOLLOWIN NFORMATION• O" ` tFJ ref !l J IS this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES El No 19 IS this all EXISTING Business LOCATION but a NEW TYPE Of regulated Business? YES ❑ No BUSINESS/FATSITY/SITE NAME 1 J Imo` ^yam SITE ADDRESS Z �I_1 VA O u�A—�% N �S e- '\L{/V ILw*— SUITE# BUSINESS PONE Vl l ��UV 83cn- Lo CITY -rv^ L STATE CA ZIP 95 30 1 I BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEY1 KEY2 1 ` Mailing Address ifDIFFERENTfrom FaciGtyAddress Attention:or Care Of(optional) l-4 5-2--C! IJ• C5Y L-k A-k- l2j J o�v,Y\� !�:tn�.br•av Mailing Address Cityra- �t ' ^ STATE C� Z SIC IP CODE (50 � l_ APN# �-/t 7 v 6 v ID� COMMENi: THIRD PARTY BILLING INFO: Complete if Billing Party is different from Property Owner or Facility Operator identified above. BUSINESS NAME 1 O• v v56v1 �SSOC. f �r1 C . Attention:orCare Of (optional) A 90 GGC C) Mailing Address D `� sJ l'1 PONE /13�(.� CITY 1 _ ` STATE C t `Pq 1 7 C2-4 dccol ur4ppRECC for fees and charges OWNER FACILITY/BUSINESS THIRD PARTY BILLING 1111 LING AND COMPLIANCE A['KNOWLEl?mtFNT: 1,the undersigned Applicant,certify that 1 am the Onwer,Operator,or Authorized Agent of this Business,and I acknowledge that all PERMIT FEES, PENALTIES,ENFORCEMENTCHARGE.S and/or HOURLYCNARGES associated with this operation will be billed to me at the address identified above as the AC'CCtunTAnnRF'.cs for this site. I 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,I 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 777��j 1 rh0.t 1 1`�LLO PLEASE PRINT SIGNATURE TITLE ?YD I C_ L ��u p^/ DRIVER'S (PHOTOCOPY REOUIRED) Approved By 1 V�Date --C]"- Accounting Office Processing Completed By .-,C.. Date ` 0 29.02.002 April 25,2003 CMADENTIAL