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San Joa^-bin County Environmental Health Nartment GREEN FORM MASTER FILE RECORD INFORMATION " R,, cus^m AirAC Fn0 FHA IICF nNl V OWNER ID# ,{-� �/„( '` CASE# UNIT IV OWNER FILE COMMET p (fit cC�+FJJRTY OWNER INFORMATION; CHErxrF OWNER CuRRENTzroNmEwrm EHD PROPERTY OWNER IYAMEYI `f,ll 7t-` ►i( A PHONE �l� \C ,4 - V J`%First MI T_ `T t Last L / ( 1 BUSINESS NAME L \ CC1 r Soc SEC/TAx ID# Owner Home Address .►� 7�_l � L � +2� � r�` DRmWs LICENSE# City �G-�c14Tc-t- , STATE Owner Mailing Address r Mailing Address City state Zip Tync nF OwnFvcrrm CORPORATION INDIWDUAL❑ PARTNERSHIP❑ FED AGENCY❑ OTHER❑ FACILITY FILE FAauw ID# CROs REP ID# ACCOUNT ID At INV# QJCOMPLETE EF LL WIN NFORMATION' 1,31,5 C� Is this a NEW Business LOCATION not previously regulated by the ENvIRONMENTAL HEALTH DEPARTMENT? YES ❑ No ❑ Is this an EXISTING Business LOCATION but a NEW TYPE of regulated Business? YES ❑ NO ❑ BUSINESS/FAaLITY/SITE NAME VAG�T LOT SITE ADDRESS v r SUITE# BuSiNESs PHONE CITY4 1`-^ 1—` STATE n n ZIP VT / 1',Z'-'(' BOARD OF SUPERVISOR DISTRICT =LOCATION CODE KEY? KEY2 I Mailing Address TfDIFFERENThom FadlilyAddress Atbention:or Care Of(opdona/) Mailing Address City STATE ZIP SIC CODE FN# COMMENT. THIRD PARTY BILLING INFO: Complete if Billing Party is different from Property Owner or Facility Operator identified above. BUSINESS NAME _ Attention:orCare Of (optional) kL- Mailing Address '5 1 \ \ �� PHONE(6`�) 7q Z CITY al,�l- \ ?Av.L- f!� STATE m tq zip cK eC=a1Tenn0z9ee for fees and charges OWNER FACILITY/BUSINESS THIRD PARTY BILLING Rn.i.iNG ANn COMPI.IANCR ACKNOWT.FnGMF.NT: I,the undersigned Applicant,certify that 1 am the Owner,Operator,or Authorized Agent of this Bhsioessyand I acknowledge that all PERMIT FEES, PENALTIES,ENFORCEMENTCHARGEs and/or HOURLYCHARGES associated with this operation will be billed tome at the address identified above as theACCOONTAnnRFC@ 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 JOAQUTN 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 ad {I hereby authorize the release of any and all results and environmental assessment information to SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTM on avai Cme time it is provided to me or my representative. APPLICANT NAME (�r PLEASE PRINT SIGNATURE TITLE , t DRIVER'S LICENSE# /f (c� -1 ,/ Q .gyp fPHDTOODPY REQUIRED) (�- Approved By/,14,/ Date ( �^t U� Accounting Office Processing Completed By Date `Z 29-02-002 April 25,2003