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San Joe uin Cot!nty_ ,Pu,blic,HealthServices Envirorlmenfai Healtft:,Qivision,,, , <br /> GREEN FORM <br /> DATEj1 MAAR FILE RECORD INFORMATION *R" <br /> UNIT IV <br /> gHADER 1REAs fon CHO at opt A OWNERID# I I Cilli <br /> OWNER FILE <br /> COMPLETETHEFOLLOW/NG PROPERTY OWNER INFORMATION.- CHECKIF OWNER CURREVTLvovntEWiTHEHD <br /> PROPERTY4v,d I PHONE <br /> GWNER NAME <br /> Fkal MI les( <br /> I•J <br /> BUSINESS NAME (�/N1 U L�� 11 I r U O /�Oa1Ut '• c}� SOD SEC I TAX ID# <br /> , <br /> Owner Home Address J IJ ` I a NicoDRIVER'S LICENSE# <br /> Urla 9s3 <br /> City $TATE &vq ZIP 7k <br /> Owner Mailing Address <br /> Mailing Address City State Zip <br /> CORPORATION❑ INDIVIDUAL❑ PARTNERSHIP❑ FED AGENCY❑ OTHER❑ <br /> qq FACILITY FILE <br /> FACILiTr ID# 00/;iq `( Caoss REF ID#' <br /> COMPLETETHEFOLLOW/NG BUSINESS/FACILITY/SITE INFORMATION.' <br /> IS this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DIVISION 9 YES Q NO <br /> Is this an EXISTING Business LOCATION but a NEw TYPE of regulated Business? YES ❑ No ❑ <br /> BUSINEss/FACILITYISITE NAME II � <br /> llS Ld fl � I V e ('O�il.tC� <br /> SITE ADDRESS C� I O SUITE# BUSINESS PHONE <br /> 1 � �15a Ura NI <br /> CITYSTATE ZIP / <br /> I ra[ qS3 -7 <br /> I <br /> I _ ,LOCACODR IIKE7LBQARDOFSOPERVISOTON <br /> Mailing Address/(DIFFERENT from Facility Address Attention: or Care Of(optional) <br /> Mailing Address City STATE ZIP <br /> 31060DE ,APN#.d. ,, �.,'.;� ✓, COMMENT: ..;. <br /> THIRD PARTY BILLING INFO: Complete if Billing Party is different from Property Owner orFacility Operator identified above. <br /> BUSINESS NAME Attention:or-Care Of (optional) <br /> Malting Address 0 a15 led f,-�--I�, PHONE Q <br /> CITY C �0 L(L ,.� Y ' STATE Vf i A_ ZIP �S�j S� C�7 <br /> J )7 <br /> 4_G_¢vNTADDRZ5$ for fees and charges OWNER FACILITYIBUSINESS THIRD PARTY BILLING <br /> BILLING AND COMPLIANCE ACKNIIW LLUGMENT: 1,the undersigned Applicant,Certify that I am the Owner,Operator,or Authorized Agent of[his Business,and I acknowledge that all <br /> PERMIT FELy,PE.N.4mrS,ENFOR('EAIENT CHARLES and/or nouRLYCIIAR(xy associated with this operation will he billed to meat the address identified above as the A('(.l)VWADHREVV <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 /> JOAQUIN COUNTY Ordinance Codes and/or Standards and STATE and/or FEDERAL Laws and Regulations. As the undersigned owner,operator,or agent of the property located at the <br /> above facility/site address, I hereby authorize the release of any and all results and environmental assessment Information to SAN JOAQUIN COUNTY ENVIRONMENTAL <br /> HEALTH DIVISION as soon as Il is available end at the same lime it is provided to me or my representative. <br /> PLEASE PRINT <br /> APPLICANT NAME SIGNATURE <br /> TITLE DRIVER'S LICENSE# I�1N' D Oaa� Q <br /> Approved By Data - i[, Ali Accounting Office Processing Completed nay =� : y '�Dete' ff . <br /> rel <br />