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n r Vis, kirk' e .nc ¢rev: J>w•m r'z'�!y^X + y , <br /> �,$�n,JdagUfflw'�ount�nifl�na���'lerttaf'klealkh.DepaftmfFri��" <br /> ,�qy� GREEN FORM <br /> OAS �a5?iE�f4Y MASTER FILE RECORD INFORMATION "MFR" <br /> g ,, Nal <br /> Y UNIT IV <br /> y...... p IQINER`,drAY.Lsa�11MIMMIMIN a..0 <br /> OWNER FILE <br /> OfcCKLs OWNER LTIRREARLYONFTLE wnNEHD <br /> COMPLETE THEFOLLOwNG PROPERTY OWNSfORMATfON; <br /> PHONE ^ <br /> PROPERTY OwxER / <br /> First An a# <br /> SoC SEC J TM ID# <br /> BUsmE55 NMaE - <br /> IL14wl /CeS <br /> DRIVER'S LICErBE# <br /> Owner Home Address <br /> City <br /> STATE IIP <br /> Owssv mial Add. <br /> Mailing Address City b1rS.!r state Lp `%o✓ <br /> rnoon �.❑ o son.... eAamrEewm❑ ern err.w❑ rs.0 <br /> P-.;.�... lt4 z'"Tr '_ d)c•�.E.lea <br /> ,a-r aa�xzpi: & Vis' <br /> �' EIQ„_. '74Si �r±=e.3:^`r: <br /> , F,!I,a1.mID,#rr <br /> 71: <br /> w Business Ls%Anon trot previousry regulated by the EIMRONMENIAL NEALTX DEPARTMENT? Yes No Iq <br /> lasrou;Business Locaro best a NEw TYPE of regulated Business? YES ❑ NO 4Xj <br /> BUnaesslFAcrrrvISITE NAME ``. <br /> ® (JlA( <br /> /J <br /> AooRaS / <br /> Sunni Buu�sttnESi PHON <br /> S <br /> 4'17,/57���AM <br /> STATE <br /> fATTEE ZIP <br /> DDy <br /> y>r"sax4 '#Y£"' xrti t ^' vim " e <br /> � i0F51F�YlSOiR'wyDISTR rI A a- �'.ate : - KE1' <br /> i <br /> Mailing Address ifDFFFERENTdom WiitYAddr Attendual or Care Of(optional) <br /> STATE ZIP <br /> Mailing Address City <br /> as _ rs,. i. ..w h <br /> or <br /> 94-5501 <br /> THIRD PARTY BILLING INFO: Completeif Billing Party is different from Property Owner or Facility Operator identified above. <br /> Attention:or Care of (optional) <br /> BttimitesSNAME <br /> PHONE <br /> Mailing Address <br /> STATE ZIP <br /> Cm <br /> ACCOLMrrwnnna S for fees and charges OWNER FACILITYIBUSINESS THIRD PARTY BILLING <br /> R C s vm T: 1,the undersigned Applil certify that 1 am Me owner,opewoy or Authorized Agent of this Bsnincsy and I a kesawtedge that all PERMIT FEES, <br /> PRNALTIE,EAFORCEAENTCHARGES andlor Houxty CHARGES associated with this Operation will be bitted to me at the address Identified above as the Acc&,n AnnR£R for this site. I also certify that all <br /> information provided on Lida application Is true and correet;and that all regulated activities will be performed In accordance with 26 applicable SAN JOAQUIN C;�herebyrdial odeshe godease of <br /> Standards and STATE and/or FEOERAL Lasa and Regulations. As the undersigned owoer.operator,or agent of the property Mcated at the above facility/me address, Y authoriTe <br /> any and all resul and environmental assessment information m SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available am at the same time it is <br /> provided to one,or my reprnentative. <br /> PtEaSEPRINT <br /> /� SIGNATURE <br /> APPLICANT NAME <br /> �orl2� K0.r0.l <br /> ICENSE <br /> TITLE •�v('t. L C L t L DRIVER'S L # <br /> -moo �' b � �r-s � '�tS �"�'t��JPxolotoPr aeautuol <br /> ,,a�,.�y.,��ea•: <br /> xH. <br /> h ' ,�...2`... AOmuiifl`tspyt9E0ts. 119 C0111p1ltld Bv.. �v*•.._n 3S,s_a",y', •Datei*`:n;9'� ,.n <br /> "-ApfBoved eYM., +.>Il'dn�>A. ,i Da !I :,',',+rte s t,«:.. <br />