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San Joa uin County Environmental Health Department <br /> GREEN FORM <br /> DATE L-310-- O e MASTER FILE RECORD INFORMATION "MFR" <br /> emacam aaeAeena EHJD 15 Oh= OWNER ID# east# UNIT IV <br /> owlul=R FILE <br /> COWL=THE FOLL097NG PROPERTY OWNER INFORMATION; dre�rrF OWNER tltxaEtvrLrotrrnEttrTtt EHD <br /> PROPERTY OWNER NAME RK— 2Uj— -[`[(j—0Zq <br /> First M) test <br /> BUSINESS NAME Por+ O� SiC 1;.v N SOC SEC/TAX ID# <br /> Owner Home Address DRIVER's LJ[Ertse# <br /> City STATE ZIP <br /> Owner Mailing Address -22_0..( W. W`5 II N" <br /> Mailing Addr�essCity �1-��V'k� h 'I State CA aP '- <br /> CORPORATION❑ INDIVIDUAL❑ PARTNEP.SHIP❑ FED AGENCY❑ OT—A <br /> FACILITY FILE <br /> FAaL rr ID# CROs REF ID# AOCOUNT ID# INN# <br /> G <br /> Is this a NEW Business LOCATION not Qrevioustyl regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ No,19 <br /> Is this an♦ExIsTING Business LOCATION but a NEW TYPE Of regulated Business? YES ❑ NO <br /> BustNesss/FAcnm/SrTENAME S-�t,c. +%i. _ Dev—re- <br /> SITE ADDRESS 'Z f3 2q2•135WgSt:i f �-h S+&-c- SUITE# Bus"E"PHONE NA <br /> Cr" S;-6C.l f L'%- STATE GQ zlP ci 5 203 <br /> BOARD OF SUPERVISOR Dr9rR= LOCATMN CODE KEY/ KEY2 <br /> Mailing Address ffD1FFFRENThom FadllfyA Attention:or Care Of(cptfcrlaq <br /> ViifMKA 1207oo �/1�q�✓�n'•Jtit �jBrQ <br /> Mailing Address City 1 A up SC' STATE vm zip <br /> SIC Coot ,/V APN# GOMMENr: <br /> THIRD PARTY BILLING INFO; Completed Billing Party is different from Property Owner or Facility Operator ddendfied above. <br /> BUSINESS NAME " W Attention:arCare Of (cpbbr&W) 09 f Scheel r� <br /> MailingAildress ZS ZS NA�D'WIU ark br+Ve f S,),fe PONE qj(0 `C12Y./'-�`J3Q7 <br /> 8 9. 11311 <br /> AE/QTY 1Grgo e � Q ZIP <br /> AGRrzAmxw-w for fees and changes SER FACiL[TYBUSINESS THiRD <br /> PARTY BILLING <br /> Bill IN'V Ann res;rvtaANCE ArrcNnu l 1 <br /> 11nJENTi I,the undersigned Applicant,certify that I am the ouvwr,lfienuor,or Autharked Agent of this Business,and 1 acknowledge that all PF.RtlITFF.F_c, <br /> PF1Y.tL7,IEC,1:'NFYIfic ,rtf;,VPCIt tRr;ES and/or HDARt.rC11A&,-msociated with this opcmtion will be billed tome at the address identified above as the Ar1^fn NT AIMRF.ee for this site. I also certify that <br /> all information provided on this application is true and correct•,and that all regulated acthities will be performed in accordance with all applicable SAN JOAQUIN COUNTY Ordinance Codes andlor <br /> Standards and STATE and/or FEDERAL[Aws and Regulations. As the undersigned owner,operator,or agent of the property located at the above fou]'WW dr I hereby authorize the release of <br /> any and all results and environmental assessment information to SAN JOAQUIN COl1ATl'EVVIRO\MENTAL HF ALTIi UEPARTP k of iiabie at the same time it is <br /> prodded to me or my representative. J <br /> APPLICANT NAME �Q SG _ p PLEASE PRurr _ SIGNATURE <br /> TITLJ: VL <br /> 1 Qem I m- Geo l 15 1 L. DRIVER'S LICENSE# <br /> f PF10To0DPY REt)DfIREDy / <br /> APP..red BY Date Aaoountlrry alike Prooasstn9Ptetr:d Br Date <br /> 29.02.002 April 25,2003 T�x <br /> Lo-q 30.7? <br />