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San Joaquin County Public Health Services Environmgntal Health Division <br /> DATE . �l O� MASA FILE RECORD INFORMATION " I RGREEN FORM" <br /> SHADED AREAS FOR EHD.USE ONLY OWNER ID# I �:,r, vhf,, .°� ( CASE.# ( UNIT IV <br /> OWNER FILE <br /> COMPLETETHEFOLLOW/NG PROPERTY OWNER INFORMATION.' CHEcKIF OWNER CURRENTLYON FILE W/THEHD <br /> PROPERTY �- PHONE C L <br /> OWNER NAME �.4 s l 5 ; t i,.I t- -5..l 1 <br /> 3 & i'— f <br /> Fust MI lest <br /> BUSINESS NAME SOC SEC/TAX ID# <br /> ���Si 5��/� L-✓1 ti�� oQ , <br /> Owner Horne Address4t,,, y DRIVER'S LICENSE# <br /> City �-0 y-'3 i STATEC`l--y� ZIP C�' Z. q <br /> Owner Mailing Address // <br /> Mailing Address City State Zip <br /> CORPORATION❑ INDIVIDUAL❑ PARTNERSHIP❑ `. (�U C.? ?;�.!>t,y i'I V'/�*' FED AGENCY❑ OTHER❑' <br /> FACILITY FILE <br /> FACILITY ID# yl CROSS REF ID# I ACCOUNT ID# T77 INV# <br /> COMPLETE THE FOLLOW/NG BUSINESS/ FACILITY/SITE INFORMATION.- <br /> Is <br /> NFORMAT/ON:Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DIVISION Z YES 4. NO ❑ <br /> Is this an EXISTING Business LOCATION but a NEW TYPE Of regulated Business 7 YES ❑ NO ❑ <br /> BUSINESS/FACILITY/SITE NAME <br /> R —1;�,v:>> �' l /Qc—f/Z— 1 '7' <br /> C. <br /> SITE ADDRESS / /r v SUITE# BUSINESS PHONE l� <br /> ( -2 ':�<—i <br /> CITY V)..%1 i STATE ZIP <br /> CJ ! Z q 't <br /> (,BOARD OF SUPERVISOR_ ( .I-OCATION CODE I__..,� . .._..L.. EY1 tbA k�''. KEY2 <br /> w . . <br /> Mailing Address if DIFFERENT from Facility Address Attention:or Care Of(optional) <br /> Mailing Address City STATE ZIP <br /> SIC CODE APN# COMMENT: <br /> THIRD PARTY BILLING INFO: Complete if Billing Party is differ r orFacility Operator identified above. <br /> BUSINESS NAME Attention:orCare Of (optional) <br /> AL 2000 <br /> Mailing Address /l D b r, w 12- PHONE <br /> CITY �C/ PERMIT/SERVICES STATE zip <br /> AG-GQLINT-AQDRE$-$ for fees and charges OWNER FACILITY/BUSINESS THIRD PARTY BILLING <br /> BILLING AND COXIPLIAN(T ACI:NOWLEDGMEN'1': 1,the undersigned Applicant,certify that 1 am the Owner,Operator,or Authorized Agent of this Business,and I acknowledge that all <br /> Pt.,RAIn'FL•'E1',PENALTI v,ENFORCEMENT CnARGEv and/or f/OfIRLYCIIARGh v associated with this operation will be billed to me at the address identified above as the AI(Y)UNT ADDRE'a <br /> for this site. 1 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 <br /> .IOAQIIIN COUN'll'Ordinance Codes and/or Standards and STATE and/or FtuEuAL Laws and Regulations. As the undersigned owner,operator,or agent of the properly located at the <br /> above facility/site address, 1 hereby authorize the release of any and all results and environmental assessment information . AN O QUIN COUNTY ENVIRONNIENTAL <br /> HEALTH DIVISION as soon as it is available and at the same time it is provided to me or my representative. <br /> / PLEASE PRINT <br /> APPLICANT NAME n�' � �( ' SIGNAT <br /> C <br /> ' DRIVER'S LICENSE# <br /> TITLE <br /> � (PHOTOCOPY REfll11RFe) <br /> Approved By Date Accounting Office Processing Completed By Date{ jJ Toe) <br /> e) <br />