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Cl I 04 I 2-0C) <br />San Joaquin County Environmental Health Department <br />MASTER FILE RECORD INFORMATION "MFR" <br />4 <br />DATE <br />SHADED AREAS FOR EH D USE ONLY <br />GREEN FORM <br />UNIT IV OWNER KM CASE # <br />.11.)01)01\16 <br />OWNER FILE <br />COMPLETE THE FOLLOWING PROPERTY OWNER INFORMATION: CHECK IF OWNER CURRENTLY ON FILE WITH END <br />CliteoPERTY nWMER-Ntrarr" PHONE <br />First MI Last <br />-BetriessatE <br />W IP\ 6V- C.— 1..\-- b•f- 5+0 a-4n ZCcieUt-10erviemti ,/ SOC SEC /TAX ID # <br />Owner Home Address 4 1 A - DRIVER'S LICENSE # <br />City <br />c4be-4-'+r1, STATE C.4 ZIP 115 2 <br />Owner Mailing Address Li .25 Af . ar1A-140 <br />Meiling Address City Statea.... Zip 1"5"---1.--. ov 2, <br />TYPF OF OwNFF/sHin <br />CORPORATION 0 <br /> <br />INDIVIDUAL 0 <br /> <br />PARTNERSHIP FED AGENCY 0 <br /> <br />OTHER 0 <br />FACILITY FILE <br />FACILITY ID # <br />bb cti9 fl\ 1-t <br />CROSS REF ID # ACCOUNT ID # INvN <br />cttb3Ltsn b <br />COMPLETE THE FOLLOWING BUSINESS! FACILITY / SITE INFORMATION: <br />Is this a NEW Business LocimoN not previously regulated by the ENVIRONMENTAL HEALTH DEPT.? YES isl No 0 <br />Is this an EXISTING Business LOCATION but a NEw TYPE of rantilatarl Rt mina..? 0 No $ it <br />541" Ctirrn' lee cle.c.i e, fo p riAlfIrrv+ ue,ti_YES <br />BUSINESS/FACILITY/SITE NAME celz, i -z,,ir, • 5 , fe -2_ z ii 0 ...., c...41- itg,k.A.L..40/4-....1- atS a.s....."7 <br />SITE ADDRESS <br />..1Cib ° 614) LI042'r / 3 00 (4) 14e± SUITE #4.441 BUSINESS PHONE <br />Cnv <br /> Oh <br />Sdrci '17V, STATE &I ZIP p 5 2 0 3 <br />BOARD OF SUPERVISOR DISTRICT LOCATION CODE REY1 KEY2 <br />Mailing Address If DIFFERENT from Facility Address Attention: or Care Of (optional) <br />Mailing Address City STATE ZIP <br />SIC CODE APN# COMMENT: <br />THIRD PARTY BILLING INFO Complete ifBilling Party is different from Property Owner orFacility Operator identified above. <br /> <br />BUSINESS NAME <br />Et4 A e-com <br /> <br />Attention: ca-,Care Of (optional) <br />; Ai 5k, <br /> <br />VOL v 255 <br />Mailing Address 6 5 s uty-5;-4,7 5 <br /> <br />PHONE(,) <br />q2- //L( 3 <br /> <br />Crry <br />a-C- titt hn tA-76 <br /> <br />STATE e4 ZIP C15137,5, <br /> <br />AnanutaAnneFs.c for fees and charges <br />OWNER <br /> <br />FACILITY/BUSINESS <br /> <br />THIRD PARTY BILLING <br /> <br />BILLING AND COMPLIANCE ACKNOWLEDGMENT: I, the undersigned Applicant, certify that I am the Owner, Operator, or Authorized Agent of this Business, and I acknowledge that all PERMIT FEES, <br />PENALTIES, ENFORCEMENT CHARGES and/or HOURLY CHARGES associated with this operation will be billed to me at the address identified above as the ACCOUNT ADDRESS for this site. I also certify that <br />all information provided on this application is true and correct; and that all regulated activities will be performed in accordance with all applicable SAN JOAQUIN COUNTY Ordinance Codes and/or <br />Standards and STATE and/or FEDERAL Laws and Regulations. As the undersigned owner, operator, or agent of the property located at the above facility/site address, thereby authorize the release of <br />any 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 my repr sentative. <br />NIN APPLICANT NAME PLEASE PRINT yo <br />ckett, 1.) 444° SIGNATURE <br />TITLE ,- <br />u (-at et 42-e-ev8 o-e-c(40c-- <br /> <br />DRIVER'S LICENSE # <br />(PHOTOCOPY REQUIRED) <br /> <br />Approved By Date Accounting Office Processing Completed By Date qk3M <br /> <br />29-02 10/12/07 <br />MASTER FILE RECORD-GREEN