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San juin County Environmental Healt, apartment <br /> DATE J j ©� MASTER FILE RECORD INFORMATION "MFR" GREEN FORM <br /> OWNER ID# 006)11, <br /> CASE# cccc:�::2c � UNIT IV <br /> OWNER FILE <br /> COMPLETE THE FOLLOWING PROPERTY OWNER INFORMATION; CHECKIF OWNER CHRREmnyONFTLEWITHEHD <br /> PROPERTY OWNER <br /> PHONE (� <br /> NAME t � ' k <br /> First MI r I last <br /> BUSINESS NAME C C, SOC SEC/TAx IO# <br /> 5T t �flN-1 C I ;�10 TSL y4o -21�� <br /> Owner Horne Address o Nti' C1 C DRIVER'S LICENSE# Q [ C C 0 v <br /> City ` J L <br /> STATE c ti� uP <br /> Owner Mailing Address <br /> q q _ <br /> Mailing Address City C ;CJ i Sial /t I PrP q 21 L <br /> TYPF CIF nWNFRCHTP rT' 1 <br /> r n---A nN❑ TNnrvrni'At. DARrNFRCHTP❑ FFn Ar— ❑ rT—❑ <br /> I <br /> FACILITY ID# J`' CROSS REF ID# ACCOUNT ID# INv# <br /> COMPLETE THEFOLLowzNG BUSINESS I FACILM SITE INFORMATION,' <br /> Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ No <br /> Is this an EXISTING Business LOCATION but a NEW TYPE of regulated Business? YES ❑ No <br /> BUSINESS/FACILITY/SITE NAME <br /> C <br /> SITE ADDRESS SUITE# BUSINESS PHONE <br /> �11r=cl9 zo9 - ti3i- 3341 <br /> CITY �T <br /> L�U� STATE /-4 ZIP <br /> BOARD OF SuPERvIsoR DISTRICT t I I LOCATION CODE I KE 1 ( KEY-2 <br /> Mailing Address ii DIFFERENTfrom Facility Address f Attention:or Care Of(optional) <br /> Mailing Address City STATE ZIP <br /> _SIC CODE APP1# ?!!!7,� _13 COMMENT: (� <br /> THIRD PARTY BILLING INFO: Complete if Billing Party is different from Property Owner or Facility Operator identifredabove. <br /> BUSINESS NAME Attention:or Care Of (Optional) <br /> Mailing Address PHONE <br /> Cm STATE ZIP <br /> Ar'COUN_T ennvacc for fees and charges OWNER FACILITY/BUSINESS THIRD PARTY 61LLING <br /> Ru t tvc %ND CmtPl I au'F A(-KNoat aGME=: 1,the undersigned Applicant,certify that I am the Oxwer,Operator,or Authorized Agent of this Business,and 1 acknowledge that all P£Rmir FEES, <br /> PE.V tL TIES,ENPORCEMEATCHARGFS and/or llOFRLt'CH.aRGFS associated with this operation will be billed to me at the address identified above as the:f CCOLYT,1 DORES. to this site. 1 also certify that all <br /> information provided on this application is true and correct;and that all regulated activities will be performed in accordance with all applicable SA.N JOAQUINCOG. rdinance 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 facilitylsite address,I r uthorize the release of <br /> am'and all results and environmental assessment information to SA`JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is availab the same time it is <br /> provided to me or my representative. <br /> PLEASE PRINT <br /> APPLICANT NAME 1. t t('�� (�!i�f_ SIGNATURE <br /> TITLE V t 1 71 C� DRIVER'S LICENSE# 1 <br /> C)' (PHOTOCOPY REQUIRED) - C (') <br /> Approved By Date Accounting Office Processing Completed By Date VI/f''j <br />