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San Joaquin County _Public Health Services Environmental;HQalth,Division <br /> MrGREEN FORM <br /> DATE11 ���� D� MAS ft, FILE RECORD INFORMATION (PIR <br /> 3/FADED AREAS FOR EHD USE ONLY OWNER ID# I �� '? �j/. I CASE# I UNIT IV <br /> DOWNER FILE <br /> COMPLETETHEFOLLOW/NG PROPERTY OWNER INFORMATION: CHECKIF OWNER CURRENTLYONFILEWITHEHD <br /> PROPERTY PHONE <br /> OWNER NAME 1 G Cy i S 1(( i !" (1 Z l _ t' <br /> F-1 MI les! i <br /> BUSINESS NAMEI±,_ r ` SO I 9 <br /> Owner Home Address y l Z— DRIVER'S LICENSE# <br /> City &0 !, / STATE`/� ZIP 2- <br /> Owner <br /> Owner Mailing Address <br /> Mailing Address City State Zip <br /> CORPORATION❑ INDIVIDUAL❑ PARTNERSHIP❑ 1 '-"L' <� �,�(�r' T i V 1_ FED AGENCY❑ OTHER❑� <br /> FACILITY FILE <br /> FACILITY ID# � CROSS REF ID# ACCOUNT D# <br /> COMPLETE THEFOLLOW/NG BUSINESS/ FACILITY/SITE INFORMAT/ON: <br /> Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DIVISION 7 YES Q/ NO ❑ <br /> Is this an ExISTING Business LOCATION but a NEW TYPE of regulated Business 7 YES ❑ No ❑ <br /> BUSINESS/FACILITY/SITE NAME <br /> SITE ADDRESS SUITE# BUSINESS PHONE <br /> (._'/(_10 L. 1(/,56 w y 6 <br /> CITY STATE�� ��!) I C" zip <br /> � S—Z U c. <br /> . . <br /> . . II <br /> :, .( <br /> BOARD OF SUPERVISOR LOCATION CODE ,KEY1 . I_ .... , .,..,.,.. .. <br /> Mailing Address/fD/FFERENTfrom FaciityAddress Attention:or Care Of(optional) <br /> Mailing Address City STATE zip <br /> SIC CODE APN# COMMENT: <br /> THIRD PARTY BILLING INFO: Complete/f Billing Party is differ �p I r or Facility Operator identirledabove. <br /> BUSINESS NAME Attention:or Care Of (optional) <br /> I IL Ch <br /> Melling Address (r r D b C• � �Z PHONE <br /> ENVIRONMENT HEAL-1 H <br /> CITY PERMIT/SERVICES STATE zip <br /> AccouNrAODRES$ for fees and Charges OWNER FACILITY/BUSINESS THIRD PARTY BILLING <br /> BILVING AND CON1PLIANCy.AcKNOWl.EDGNIFN'r: 1,the etfdersigned Applicant,cerlify Iha(1 am the(honer,Operator,or Aalhorized Agent of this Business,and 1 acknowledge that all <br /> PERA11rFOI v,Pi-.'sv.71YS,EN1oR(T:A11TN1'01.1R(XV kindl�o/l'FIOI'RLr01AR(;EV assOCillled{Villi this operation will he Milled to ale at file address identified above Its the ACcomr,fmmFCS <br /> for(his site. I also certify(hal all information lmovidelYl111 Ibis applicalion is true and correct;all(]that all regniated activities will be performed in accordance With all applicable SAN <br /> .I(IAQIIIN COUN 11'Ordinance(odes and/Or Standards and S'PATE and/01'FEDERAL LRW9 flint 149niallons. As file undersigned owner,operator,or agent of the property located at the <br /> above faciiily/site address, I hereby aulhorire (he reiense of tiny and Al resulls and environmental assessment Information 1 . ANO OtIIN COUNTY ENVIRONMENTAL <br /> IIE:\I:TII DIVISION as soon as it is avalilahie and at the slime(line it is providevl to ale or illy representative. <br /> PIEASE PRINT c, � <br /> APPLICANT NAME (F" <br /> �' SIGNATYRIs <br /> TITLE �� �/� 1 DRIVER'S LICENSE# <br /> r IPHOTOCOPY REQUIll ill <br /> Approvod By Oate Accounting Office Proaesaing Completed B Date / v <br />