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San Joa Din County Public, Health Services Environmental Health_Divisiorr: , <br /> GREEN FORM <br /> MASTER FILE RECORD INFORMATION <br /> DATE i�, ` 5,F R" <br /> e �AS E OueeOytr OWNER ID# I I CASE* I UNIT IV <br /> OWNER FILE C( �j <br /> COMPLETE THEFOLLOWING PROPERTY OWNER INFORMATION: <br /> CHECAIF OWNER CURRENTLYON FILE WITH EHD <br /> PHONE <br /> PROPERTY <br /> OWNER NAME <br /> Fvsl An last <br /> BUSINESS NAME //�� 1����G� �,vG_ SOC SEC I TAX ID# <br /> DRIVER'S LICENSE# <br /> Owner Home Address <br /> STATE ZIP <br /> City <br /> Owner Mailing Address <br /> State Zip <br /> Mailing Address City <br /> VNERRHIP FED AGENCY OTHER❑ <br /> [ON 11 INDIVIDUAL❑ PARTNERSHIP❑ <br /> ��Y�, FACILITY FILE <br /> FAcILrn ID# <br /> OoI t3CROSSREFID# I ACCOUNTID# '04,%' <br /> COMPLETETHEFOLLOWING BUSINESS I FACILITY I SITE INFORMATION <br /> YES C] No <br /> Is this a NEW BUSIn85S LOCATION net preV10U51y regulated by B18 ENVIRONMENTAL HEALTH DIVISION <br /> ❑ <br /> YES C1 No [IIs this an EXISTING Business LOCATION but a NEw TYPE of regulated Business 7 <br /> BUSINESS/FACILITY/SITE NAME <br /> /G, / U v✓� SUITE# BUSINESS PHONE <br /> SITE ADDRESS <br /> CITY d.-y II STATE zip <br /> ..,CATION ODE KEY'), d».. ..� ..,ss..,n LK€+'? <br /> KOARp OF SUPERVISOR It. .,..I_ � I...,.� ._I I .,.,_...... <br /> Mailing Address if DIFFERENT from Facility Address Attention. or Care Of(optional) <br /> STATE zip <br /> Mailing Address City <br /> SICOODE APN# COMMENT' <br /> THIRD PARTY BILLING INFO: Complete if Billing Party is differentfrom Property Owner orFaclllty Operator Identified above <br /> Attention:or Care Of (optional) <br /> BUSINESS NAME <br /> PHONE <br /> Mailing Address <br /> STATE ZIP <br /> CITY <br /> ,gOOQL/NTAooREss for fees and charges OWNER FACILITY/BUSINESS THIRD PARTY BILLING <br /> 111I.I.IN('AND C(INIPI.IANCI;A['RNOWI.Eu('NIENT: I,the undersigned Applicant,certify that I am the Owner,Opernlor,or Authorized Agenl of this Business,and I acknowledge that al' <br /> P£RART F£FS,PENA(.i'!ES',ENFORC£AI£'N]CHARGES and/or HOURLY 0IARGF_9 associated with this operation will he billed ionic at the address identified above as the A('COUN/'ADDREY <br /> for this site. 1 also certify that all iurlu malion Provided on this application is true and correct;and that all regulated activities will he performed in accordance with all applicable SA <br /> JO.AQUIN COUN'IN Onlinance Codes and/or Standards and S'I'A're:and/or FE.DEIIAI.Laws and Regulations. As the undersigned owner,operator,or agent of the pro .(y located al t <br /> above facility/site address, I hereby authorize the release or any and all results and environmental assessment information to SAN JOAQUIN COUNTY ENVIRONMENT. <br /> IIF.AIA11 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 C-JU #ZSIGNATURE <br /> tzi L <br /> o /1DRIVER'S LICENSE# <br /> TITLE <br /> Data <br /> <Approved By ' Date lI - Accounting Office Processing Completed . <br />