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I <br />AccoutcrApaeEss for fees and charges <br />OWNER <br /> <br />FACILITY/BUSINESS <br /> <br />THIRD PARTY BILLING <br />BUSINESS NAME <br />E-Ck T....a A Attention: 'Care Of (optional) <br />13 w ;to Sk-: a_ <br />Mailing Address 6 un 4,--5 ve_ • 5v .4-e_ 2-55 PHONE 110 67 24 - /LI 3 <br />Crry <br />(fit. INA <br /> STATE C4 ZIP q 6 z <br />Date Date <br />29-02 10/12/07 MASTER FILE RECORD-GREEN <br />Accounting Office Processing Completed By Approved By <br />San Joaquin County Environmental Health Department <br />DATE <br />MASTER FILE RECORD INFORMATION "MFR" GREEN FORM <br />SHADED AREAS FOR END USE ONLY OWNER IDX CASE* 6Lbobovno <br />OWNER FILE <br />UNIT IV <br />COMPLETE THE FOLLOWING PROPERTY OWNER INFORMATTON: cHEctor OWNER CURRENTLY ON FILE KITH EHD <br />CflaCWV.TV rtwt,rFI-NAVE- PHONE <br />First MI Last <br />-liktegsaf&E v.) n e-r 3+0 a-40n R.ccieut-( orrvie,t-t-J ,, sc.. sEe n-Ax ID# <br />Owner Home Address p 4 i A - DRIVER'S LICENSE* <br />City STATE 04 ZIP <br />Owner Mailing Address <br />14 .25 /q . 4'Crlat° <br />Mailing Address City ...-11-0 State61_ Zip <br />TYPIF OF OwNFRRHIP <br />CORPORATION 0 <br /> <br />INDIVIDUAL 0 <br /> <br />PARTNERSHIP FED AGENCY OTHER 0 <br />FACILITY FILE <br />FACILITY ID SO <br />ikb IC414.69 <br />CROSS REF ID* ACCOUNT ID # <br />f I <br />INvX <br />'ct‘i1`b3LISrl d <br />COMPLETE THE FOLLOWING BUSINESS / FACILITY / SITE INFORMA770N: <br />Is this a NEW Business Loc.A-rioN not previously regulated by the ENVIRONMENTAL HEALTH DEPT.? YES )81 No 0 <br />Is this an EXISTING Business LOC.ATION but a NEw TYPE O. f renulatad Fti itzinwee9 YES 0 No S. <br />-i-v 5.4-0c-rre BUSINESS/FACILITY/SITE NAME 5 Az, 1 -.... 14,, 1._,,, . 5 2- z_ , ii„..„....,,..\-- 1140, j (4... <br />SITE ADDRESS <br />9Ci 0 E.LA) tio e-r- / 3 oc.) (A .), blit-r -t_e_+ SUITE #4)4 BUSINESS PHONE ,04 <br />Cm., <br />540ci 'f-tv, STATE ce9 ZIP 95 2 c; <br />BOARD OF SUPERVISOR DISTRICT LOCATION CODE KErl KEY2 <br />Mailing Address if DIFFERENT from Facility Address Attention: or Care Of (optional) <br />Mailing Address City STATE ZIP <br />SIC CODE APN N COMMENT: <br />THIRD PARTY BILLING INFO Complete //Billing Party is different from Property Owner orFacility Operator identified above. <br />BILLING AND COMPLIANCE ACKNOWLEDGMENT: I, the undersigned Applicant, certify that lam 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, I hereby 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 />APPLICANT NAME eft: PLEASE PRINT in , 7 <br />Kicina, i3 i t,c4I.147(1 . <br />TITLE 14-avt 242-e-ov8cl - <br />SIGNATURESIGNATURE <br />DRIVER'S LICENSE # <br />(PHOTOCOPY REQUIRED)