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San Joao " i County Environmental Health DF qment <br /> DATE « » GREEN FORM <br /> MASTER FILE RECORD INFORMATION MFR <br /> SHADED AREAS FOR EHD USE ONLY OWNER ID# 41,J CASE# 0 0001976 UNIT IV <br /> ob b <br /> OWNER FILE <br /> COMPLETE THE FOLLOWING PROPERTY OWNER INFORMATION., CHECKIF OWNER CURRENTLYONFILEWITH EHD <br /> PROPERTY OWNER NAME PHONE <br /> First M/ Last <br /> BUSINESS NAME C ,1 S D I S t t G1- I SOC SEC I TA7(ID# <br /> Owner Home Address DRIVER'S LICENSE# <br /> City STATE ZIP <br /> Owner Mailing Address ; 9 ,74 E: C hCG-r..te-,- Way <br /> a P 0 . -B D`/ 7/1/1 g <br /> Mailing Address City S�t6 C I,�C Y\.- <br /> v v J� sCCf�C State C Zip O�5--2— <br /> TYPF OF OWNERSHIP <br /> CORPORATION❑ INDIVIDUAL❑ PARTNERSHIP❑ FED AGENCY❑ OTHER <br /> FACILITY FILE <br /> FACILITY I D# CROSS REF ID# ACCOUNTID# INV# I�-7��f�vilE �� i L'—M ��S-S�!L <br /> C�-7 <br /> COMPLETE THE FOLLOWING BUSINESS/FACILITY I SITE INFORMATlo <br /> Is this a NEW Business LOCATION not Previously regulated by the ENVIRONMENTAL HEALTH DEPT.? YES NO ❑ <br /> IS this an EXISTING Business LOCATION but a NEW TYPE Of regulated Business? YES ❑ NO X <br /> BUSINESS/FACILITY/SITE NAME <br /> SITE ADDRESS _ <br /> SUITE# BUSINESS PHONEState, �DV e 9 . � <br /> CITY L)C DY\ STATE C L� ZIP <br /> BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEY1 KEY2 f <br /> Mailing Address KD/FFERENTfrom Facility Address Attention:or Care Of(optional) (^ <br /> W <br /> Mailing Address City STATE ZIP <br /> m <br /> SIC CODE [APN:#:= �EOMIIE— <br /> THIRD <br /> PARTY BILLING INFO: Complete ifBilling Party is different from Property Owner or Facility Operator identified above. W <br /> BUSINESS NAME Attention:orCare Of (optional) <br /> U�c©I� co�svt-rA•�-�s ���., e►'FIz.IS c,�� rac..l <br /> Mailing Address AP4C',-?I <br /> 8R1 S 4QrT- PHONE 92S--371- <br /> CITY L.1UE2r-fo2C– STATEn AZIP 9'VS5-z-" <br /> ACcouNTADDREss for fees and charges OWNER FACILITY/BUSINESS F� THIRD PARTY BILLING <br /> BILLING AND COMPLIANCE.ACKNOWLEDGMENT: [,the undersigned Applicant,certify that I am the Owner,Operator,or Authorized."Igent of this Business,and 1 acknowledge that all PER HT FEET, <br /> PE.NAL77t:S,ENFOR('EME'N7*0i IRGES and/or ii0(/RLI'CIL4RCElS associated with this operation will be billed to me at the address identified above as the ACCOUNTADDRECS for this site. I also certify that <br /> 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 COUN'T\ Ordinance Codes and/or <br /> Standards and S"r.ATE:and/or FEDERAL Laws and Regulations. As the undersigned owner,operator,or agent of the property located at the above facility/site address,I herebN.y authorize the release of <br /> any and all results and environmental assessment information to SAN JOAQUIN COUNTY ENVIRONNIENTAL HEALTH DEPARTNtEN"f as soon as it is available and at the same tine it is <br /> provided to me or my representative. f� <br /> APPLICANT NAME PLEASE PRINT SIGNATURE <br /> r1-l2 I S �t c�/�+7ZM L/ <br /> TITLE sp, T -63 r SC.I�+T1ST� rV- ��C�� DRIVER'S LICENSE# ` ' 8 <br /> {PHOTOCOPY REQUIRED) /� <br /> Approved By Date Accounting Office Processing Completed By I Date <br />