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San Jo' -ain County Environmental Health F irtment GREEN FORM 1�DATE �'� MASTER FILE RECORD INFORMATION MFR" rl t� UNIT IV OWNER YD# _ CASE# AO O .....FO EMD DSE ONLY OWNER FILE i CHECKIF OWNER CURRENTLYONFILE WITH EHD ❑ COMPLETETHEFOLLOWINGPROPERTY OWNER INFORMATION: PHONE PROPERTY OWNER NAME i Ml Last I First - Soc SEC/TAX ID# BUSINESS NAME _1 GV DmitER'S LICENSE# Owner Home Address j City towner Mailing Address + ) 0 ( �J(J Y V iV State -A � 17 P I Mailing Address City ( � f .� !TYPE OF OWNERSHIP OTHER El j CORPORATION INDIVIDUAL❑ PARTNERSHIP❑ FED AGENCY❑ FACILITY FILE �.FA[ILm ID# GRoss REP ID# AccouNTID# INV# COMPLMTHE FOLLOWING BUSINESS/ FACILITY SITE INFORMATION. Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES No ❑ ❑ Is this an EXISTING Business LOCATION but a NEw TYPE of regulated Business? YES ❑ No ❑ ' I BUSINESS/FACILrrY/SITE NAME SURE# BUSINESS PHONE t: I SITE ADDRESS f STATE. ZIP CITY BOARD OF SUPERV35OR DISIRICr LOCATION CODE KEYl KEy2 _ E I Mailing Address rfDIFFEREIVTfrvm FadlityAddrew Attention:or Care Of(OPhII Mailing Address City STATE ZIP I• I!� < SICCOOS APN# �-E �^ I jTHIRD PARTY BILLING INFO: Complete if Billing Party is different from Property Owner or Facility Operator identified above. Ic BUSINESS NAME / Attention:orCare Of (optional) j Mailing Address � , 2s PHONE S � t f j cm STATE ZIP I for fees and charges OWNER FACIUTYIBUSI NESS THIRD PARTY BILLING BILLING AND COMPLIANCE ACKNOWLEDGMENT: 1,the undersigned Applicant,certify that 1 am the Owner,Operator,or Authorized Agent of this Business,and I acknowledge that'311 PEROIrFEES, ;PENALTIES,EA'FORCEMEATCHARGEs and/or HouR),YCHARGEs associated with this operation will be billed tome at the address identified above as the ACCOUNTADDRFSS for this site. I also certify that !all information provided on this application is true and correct;and that all regulated activities will be performed in-accordance withal]applicable SAN JOAQUIN COUNTY Ordinance Codes and/or !Standards and STATE andlor FEDERAL Laws and Regulations. As the undersigned owner,operator,or agent of the property located at the above facility/site address,1 hereby authorize the release of 1' j`any and all results and environmentat assessment information to SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTM as soon as it is available and at the same time it is provided to me or my representative. PLEASE PRINT •. APPLICANT NAME116E{T SIGNATURE S 1 F tom'- 1t TITLE _ R P_CAt _S 'SAX ID S}• ��3 1J' as`� (PHOTOCOPY REQUIRED) ` ! Approved By Date Accounting Office Processing Completed By Date on_nm A—;1 1c Innz ' II