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San J.._auin County Environmental Health -partment <br /> DATE MASTER FILE RECORD INFORMATION "MFR" GREENFORM <br /> SHADED AREAS FOR EHD USE ONLY OWNER ID# i t) 0 ( CASE# F UNIT IV <br /> 111 OWNER FILE <br /> COMPLETETHEFOLLOW(NGPROPERTY OWNER/NFORMAT/ON: CHECK/F OWNER CURRENTLYONFFLEmTH EHD <br /> PROPERTY OWNER NAME PHONE o2Q5' 3 <br /> First Ml Last <br /> BUSINE33 NAME � jy nn !J � '� I C) Soc SEc/TAx ID# <br /> Owner Home Address W t DRIVER'S LICENSE# <br /> CRY STATE ZIP <br /> Owner Melling Address , t / O / (.71�/PDI- Vfir '2IVstaMalling Address City / <br /> ZIP C7(p5 2�� <br /> CORPORATION❑ INDIVIDUAL❑ PARTNERSHIP❑ FED AGENCY❑ OTHE <br /> FACILITY FILE ^ <br /> FACILITY ID# �yN�3 CROSS REF I D# ACCOUNT ID# �7 INV# <br /> COMPLETE THEFOLLowiNG BUSINESS/FACILITY/SITE/NFORMAT/ON: �P <br /> IS this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPT.? YES ❑ NOX <br /> IS this an EXISTING Business LOCATION but a NEW TYPE of regulated Business? /^ YES ❑ No I <br /> BUSINESS/FACILITY/SITE NAME <br /> SITE ADDRESS / S ITE# BUSINESS PHONE <br /> CITY STATE ZIP <br /> BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEY1 KEYZ <br /> Mail Ing Address KO/FFERENTlhornFacNKyAddress Attention:or Care Of(opNone/f <br /> Mailing Address City STATE ZIP <br /> SIC CODE :�:=[APN# COMMENT: <br /> THIRD PARTY BILLING INFO: Complete ifBilling Party is different from Property Owner or Facility Operator identified above. <br /> BUSINESS NAMEI V �� D 9:OCar' �(/�#J0�Ia/f6t� ^_ <br /> Mailing Address PHONE <br /> ��v2 iz��e <br /> CITY �f'(I D (iL L/ K ��J STATE/ ZIP <br /> AccouAfTAooRESS for fees and charges OWNER FACILITY/BUSINESS THIRD PARTY BILLING <br /> BILLING AND COMPLIANCE ACKNOWLEDGMENT: I,the undersigned Applicant,certify that I am the Owner,Operator,or Authorized Agent of this Business,and I acknowledge that all PERMtTFEEs, <br /> PENALTIES,ENFORCEMEtiTT CHARGES and/or HOURLY CHARGES associated with this operation will be billed to me at the address identified above as the ACCOL:A4ADDREss 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 COUNT) 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,1 hereby authorize the release of <br /> any and all results and environmental assessment information to SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as as it' able and at the same time it is <br /> provided to me or my representative. <br /> APPLICANTNAME`� �� v� /P SIGNATOR <br /> TITLE op" DRIVER'S # 7- <br /> lop" <br /> r' PHOTOCOPY UIRED <br /> -73 <br /> Approved By Date Accounting Office Processing Completed By Date Ita <br /> 29-02 10/12/07 MASTER FILE ECO D- REEN <br />