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f <br /> San Jopuin County Environmental Health Detaartment <br /> DATEGREEN FORM <br /> MASTER FILE RECORD INFORMATION "MFR" <br /> sdwEOARrws xamguae ONLY OWNERID# Cath UNIT IV <br /> 0 <br /> OWNER FILE <br /> CommErErNEFOL1owNGPROPERTYOWNER hwoRManoN: Ch IF OWNER CUR/aEMLroseFaxilimrEHO ❑ <br /> ' p <br /> PndrERrt,OWNDINAME �r.T "` > % <: T2s "'"^ PHONE <br /> ,/w�' First MI Last BuesEeh NATE 7+_o-nJt"' rvr'G.61�l+v N'Y- SOC 9ECITAZ ID# <br /> OtMter Home Address ORNes'h UcsisE# .,. <br /> City SIAM ZIP <br /> Owner"this Addrar <br /> Meiling Address CRy �%n :'>'-� S zip <br /> CORPORATION❑ INplMount❑ PARTNER9HW❑ FEDAOENCY❑ Oi ER❑ <br /> FACWTY FILE <br /> FACILITY IDK Gf� O 5 Cliche RBF 10# Acco 3D# INv# \ <br /> COMPLETETNEFOLLowNG BUSINESS/FACILITY/SITE/NFORM777oN: <br /> Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPT.? Yes ❑ No R' <br /> Is this an E%ISTING Business LOCATION but a NEW TYPE of1regulated <br /> ylBusiness? Yu ❑ No Imo" <br /> BusibessfIcAaure/SRENAME <br /> arts Ao ss �0 4 srV s (� `��' Shan# Buhtatas PHONE <br /> Cm � STArs:LA- Ln 9-5':1-& 'Z <br /> BOARD OF atwERYlson DlsrRicr LOCATION CODE KEYi KLY2 <br /> Melling Address HDIFTEREVTfl,,sam Fec/WAddresa Attention:or Care Of(opGbne9 <br /> Mailing Address City STATE ZIP <br /> SIC Once <br /> APN# CINWENi: <br /> THIRD PARTY BILLING INFO: Complete ifBilling Party is different from Property Owner or Facility Operator identified above. <br /> BUiscim NAME AOentlon:nrCmm Of fopcianal) <br /> Mailing Addreae 5 /`!e e)/✓ '.;U.✓r' <� PftoNE e'3f `' 3 �/ <br /> Cm "� ` '�-.�rR f1!o "�..+'j7S STATE ll ZIP <br /> 5-z!� o t <br /> Afor fees and chargee OWNER FACILITY/BUSINESS THIRD PARTY BILLING <br /> IhutvriCOMPLI NC ACKNOWIJIDCMF : 1,the undersigned Applicant,certify that I am the(lamer,Ofrerater,or AWhoreed Agent of this Business,and I acknowledge that all PERsirr R7 Fs, <br /> P£NAOIBt,ELFosas EAT CHARGES and/or NOQRLY CHARGFS associated viiih this operation will be billed to me at the address Identified above as the ACCVOATAa1MF_SF for this site. f also certify that <br /> all information provided on this application is true and correct;and that all regulated activitin will be performed in accordance with all applicable SAN JoACCSN Cofw Ordinance Codes and/or <br /> Standards and SriTE and/or Fs:s FR Laws and Regulation.As the undersigned owner,operator,or agent of the property located at the above taellity/site address,I hereby amhodu the reNau of <br /> snv 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 it is <br /> provided to me or nn representative. <br /> APPLICANT NAME PL�se PmNr SIGNATURE <br /> TITLE DRIVER'S LICENSE# <br /> IVHGTnnOT REOumsnl r <br /> Approved By para Announsrp O#Iro Praceuing Completed BY DsM O O <br /> 29-02 10:12x0' MASTER FILERAY'ORD-GREEN <br />