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Sa"uin County Environmental Healt"rtment <br /> DATE to/Z 7 MASTER FILE RECORD INFORMATION "MFR" GREEN FORM <br /> OWNER ID# CASE# UNIT IV <br /> OWNER FILE <br /> MAddress <br /> ttowrNGPR P TY WNER I/VFORMATION; o+Ecxl' OWNER CvRRExnyONrrcEMr 7-H EHD <br /> �1 r, c r;- :l,�r� PHONE <br /> First MI Lost <br /> SOC SEC/TAX ID# <br /> s <br /> PO 3O 5� SL� # <br /> ILV <br /> �, STATE Tx Zw 7- <br /> Owner Mailing Address <br /> v5 <br /> Mailing Address City <br /> s 21p 721 c7 <br /> C.T7. IHDNMAL❑ Pm *x%ar❑ FED AGENCY❑ =13 <br /> FACILITY FILE <br /> FACnrrr ID C CAoss Rep ID# 1ACCOuprr ID# IMI# <br /> J F) � 2 <br /> Is this a NEW Business LOCATION not prevkMstV regulated by the ENvtR0NMeNrAL HEALTH DEPARTMENT? YES No ❑ <br /> Is this an EXE571M Business LOCATION but a NEW TYPE of regulated Business? Yes ❑ No (� <br /> Btlsmts/FACIIITY/SITE NAME <br /> SHE ADDRESSI SurTE# BUSUMESS PHONE <br /> P (� ZC�9 33 /7 <br /> CITY <br /> rA z' 9 5 2�0 <br /> BOARD OPSUPERVOM DtoRwr Loww"CODE KEri KEY2 <br /> Maning Address IfDIATAMrhgm Fsdl1ty.4ddres Atbend":or Care Of(optlona/) <br /> EMaI11ngAMddr—msC1tySTATE by <br /> MN# CDS, <br /> THIRD PARTY BILLING INFO: Complete if Billing Party is different from Property Owner or Facility Operator identified above, <br /> BtISD+Ess NAME Atterttlfxt:orCare Of (optlwraq <br /> VE <br /> Failing JIK0 F - 5 V J(E T Nc- <br /> Malling Address �,J/'y-t / J � � 'N�U`, �d ' / <br /> CM <br /> 11 W SrA,E 7 9 Z 6vC�a <br /> 1g14 <br /> 9G�OfN�6t2Gg�for fees and charges OWNER FACILITY/BUSINESS <br /> HI D PARTY BILLING <br /> Rus srvr.AND COMPLIANCE Arkrvowe rn:rcwr: 1,the undersigned Applicant,tertify that I am the Owner,Operator,or Authorized.-Igen of this Business,and I acknow ge f at all PERmir FEes, <br /> PEVAUMS,ENh'ORCE.NENTCHARC S and/or HOURLY CHAROFS associated with this operation will be billed to me at the address identified above as the for this site. 1 also certify that <br /> all Information provided on this application Is true and correct;and that all regulated activities will he performed in accordance with all applicable SAN JOAQuiN COUNTY Ordinance Codes and/or <br /> Standards and STA rE and/or FEDERAL Laws and Regulations. As the undersigned owner,operator,or agent of the property located at the above facillty/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 soon as it is available and at the same time His <br /> provided to me or my represent <br /> PLEASE PRINT <br /> APPLICANT NAME `I__ D — V t`�'/J SIGNATU <br /> f7S t <br /> TITLE ,DRIVER'S LIC1W <br /> /) <br /> PHOTOCOPY REOUIRED) s + <br /> Appraxi <br /> BY Wee '=c ng Oflt-Pr-e-hw completed By <br /> 29-02-002 ,April 25,2003 Ate 37 <br /> U�fI <br /> DENTIAL <br />