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San Jr in County Environmental Health <br /> DATE `tS partment <br /> 4 MASTER FILE RECORD INFORMATION "MFR" GREEN FORM <br /> OWNER ID# ..."al <br /> , - CASE# UNIT IV <br /> OWNER FILE <br /> COMPLETE MEFOLLOWING PROPERTY OWNER INFORMATION; <br /> [>,EfKrF OWNER CURKEnnrO,vFnE wrTHEHD ❑ <br /> PROPERTY OWNER {•/' J/ <br /> NAME /'�r 1/MI/r,e In /[ �Q/ PHONE <br /> *3 ` "Y <br /> ✓ First /•(J `�' / /� �7 <br /> MI ast <br /> BUSINESS NAME �_ <br /> SOC SEC/TA%ID# <br /> Owner Home Address `J <br /> / DRIVER'S LICENSE# <br /> G <br /> city O / <br /> STATE 9S� ff0 <br /> Owner Mailing Address <br /> Mailing Address City <br /> TvoP nrn.,. State Zip <br /> rna,nr,ennu❑ Txnrvrnuei ❑ Deoixaxwio _ r� 1� <br /> Fun Gccury I � (lruco� 1 <br /> . .'"`• > + ACCOUINV# <br /> EACTLT If SITE &fVgMTW <br /> Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? <br /> Is this an E2IST1NG Business LOCAnON but a NEW TYPE of regulated Business 1 YES No <br /> BUSINESS/FACILITY/SITE NAME YEs (] No <br /> � �tjl Oa Lf 5 p/o <br /> SITE AooREss <br /> sum# BUSINESS PHONE <br /> Cm ell <br /> STATE ZIP <br /> Mailing Address ifOfFFERENTfrom Favi/itygddress <br /> /< Attention:Or Care Of(Optional) <br /> Marling Address Clty <br /> G a v'i STATE ZIP <br /> IC,'C9R5' a A <br /> THIRD PARTY BILLING INFO;„COmplete if Billing Party isdifferentfrom Property Owner or Facility Operator identified above. <br /> BUSINESS NAME <br /> Attention:Or Care Of (optional) <br /> Mailing Address <br /> PHONE <br /> QTY <br /> STATE uP <br /> ACCQLWTADQRE5S for fees and charges <br /> OWNER FACILITYI6USINESS <br /> THIRD PARTY BILLING <br /> BLILLINC ANu roll, <br /> 1,the undersigned Applicant,certify that 1 am the Owueq O ermor, <br /> PenetTres,ErvrORCE,bEAT CHARGES and/or/IOURLY CHARGES associated with this operation will be billed to me athe address ide or , above as thesdrrm emr,t nJ,1 acknowledge that all Pt'xnnT FEes, <br /> informadon provided on this application is true and correct; and that all regulated activities will be performed in accordance with all applicable SAN JOAQmE CounTv <br /> for this site. I also certify Ordinance Codes that all <br /> Standards and STATE and/or onmenA6 Laws and information <br /> As the undersigned owner,operator,or agent Of the property located at the above facility/site address,I hereby Authorize hedrelease'of <br /> any and all results and environmental assessment informatlon to SAN IOAQUM COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br /> provided[o me or my representative. <br /> P ce .PRINT <br /> APPLICANT NAME 'I. C <br /> SIGNATURE O� <br /> /!� <br /> TITLE <br /> G t�p M fl//T� / DRIVER'S LICENSE# <br /> Aw„ y (PHOTOCOPY REOUIRi <br />'mow :. a _i/CSCdUIItit10.0�101 ,:�.u.� <br /> .. Di! ... �pfp�Itl7aCQmRletedtff <br /> J <br />