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'__—_' - --_ - - - '1+r+=.... .. .-.,w•Yu s..4S�..�1_w 1.�11JV1.1♦41 cf.14}4114U VIV.I+.71Sl11•ti';=�1'��y�r,-a�i.�ri.ao+wq;,;�� <br /> DATEIF MASTiF(aILE RECORD INFORMATION "h. :" <br /> �• GREEN FORM <br /> . .+y;,1.✓L4 (`.-y,Td`T�y rJt t�+, �'-�'�° t'r 'j <br /> IIf�EPZEk3fom <br /> .�MDu�EOyLYr ,6Asl*�s , UNIT IV <br /> x <br /> OWNER FILE <br /> OMPLETETHE FOLLOWING PROPERTY OWNER /NFORMAT/ON: CHEcK/F OWNER CURRENTL YON FILE W/THEHD <br /> PROPERTY '{f PHONE <br /> OWNER NAME I `1 j S �eJ trLc,n� I' r?n of LL 31-2 - 143 -y911 <br /> Fist M1 las( <br /> IUSINESS NAME � LCL SOC SEC/TAX ID# 33�-S6-9o7°� <br /> )Wner Home Address DRIVER'S LICENSE# K NO_SE()7_II 4 <br /> 'ity tCa STATE�� ZIP 1`6�l_S <br /> Iwnor Mailing Address lV <br /> Su, <br /> Railing Address City I .(e State L Zip /U 6 <br /> :ORPORATION❑ INDIVIDUAL❑ PARTNERSHIP❑ FED AGENCY❑ OTHER❑ <br /> FACILITY FILE <br /> ssn` :`"tq. ... �h : » <br /> croR�rtl0 _. � ' CCOUNr D#Li <br /> ACUtiy9ID.#!- <br /> OMPLETE THE OLLOW/NG BUSINESS/FACILITY/SITE INFORMATION: <br /> s this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DIVISION 7 YES NO ❑ <br /> %this an EXISTING Business LOCATION but a NEW TYPE Of regulated Business? YES 7❑E] NO <br /> IUSINEss/FACILITY/SITE NAME <br /> Cfossr0�,�.� -hQJSTt,wI <br /> ,ITE ADDRESS I 11 11 // I' SUITE# BUSINESS PHONE <br /> If�� (k(Jt L)Actjc-kOe,� Puff.- ' —,'E. LOsr~4r' 0� lJ&i� >. <br /> ATY L UJ LA <br /> STATE L A ZIP <br /> rix 1 '• -IJJ I� .1 t .r-ay4.,y l t -t' t .: , t 4;/ <br /> i .pF3UPERV190R _._..>l .. (�OC/1TION_f`iOQE. <br /> - - <br /> lalling Address/fD/FFERENTfrom Facit/tyAddress Attention:or Care Of(optional) <br /> failing Address City STATE zip <br /> �*;*t + utas - v �xw� a' tw <br /> r„'F µ iR h xekS+;xh 7nctc »suixinrdl r <br /> �C Coota.K ., ,* �, ,t{f�, `APN#y S" a5 <COMMENT' 5 ra+» tl kxi.8$tY�G VOW <br /> 'r 0 Y <br /> IIRD PARTY BILLING INFO: Complete if Billing Party is different from Property Owner or Facility Operator identifiedabove. <br /> WSINESSNAME � n •�� Attention:or Care Of (o Uona/J I <br /> � 1 Vj 11��0 C/1 <br /> failing Address S I lel �O PHONE <br /> ATY ` / O Co STATE zip <br /> 1twt2yATADDRESS for fees and charges OWNER FACILITY/BUSINESS THIRD PARTY BILLING <br /> .IANC AND COMPLIANCE ACKNOWLEDGMENT: 1,the undersigned Applicant,certify that 1 am the Owner,Operator,or Author/zed Agent of this Business,and 1 acknowledge(hal all <br /> maT FEES,PENALTmv,ENFoRCEmENTCHARGES and/or HOURLY CHARGES associated with this operation will be billed tome at the address identified above as the ACY'Ou1VTADDREcs <br /> (his site. 1 also certify that all information provided on this application is(rue and correct;and that all regulated activities will be performed in accordance with all applicable SAN <br /> 1QutN COUNTY Ordinance Codes and/or Standards and STATE and/or FEDERAL Laws and Regulations. As the undersigned owner,operator,or agent of the properly located at(he <br /> we facility/site address, I hereby authorize the release of any and all results and environmental assessment Information to SAN JOAQUIN COUNTY ENVIRONMENTAL. <br /> ALTII DIVISION as soon as It is available and at the same time it Is provided to me or my representative. <br /> PLEASE PRINT SIGNATURE /�y <br /> PPLICANT NAME �j L�qe ) -f '�q I ()t'f <br /> ITLE PrJ eJ I qA(A opme^ DRIVER'S LICENSE# <br /> (PHOTOCOPY RFomRFnImum <br /> *. <br />