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San Joaquin County Public Health Services Environmentakk Ri'vis�n <br /> :__ -GREEN FORM <br /> DATE ^ 900 MAST* FILE RECORD INFORMATION " " <br /> AUG <br /> 1 7 z000 UNIT IV <br /> SHAOED.ARFAs FOR€HD USE ONLY ,OWNER IO# CASE# <br /> OWNER FILE <br /> :OMPLETETHEFOLLOWINGPROPERTY OWNER INFORMATION.' CHECK IF d LY0NFILEw1rHEHD <br /> PROPERTY PHONE LJj �J d 1G► X�y 'G p' <br /> OWNER NAME ( ) U 7 D O 2,, <br /> Fust MI last <br /> BUSINESS NAME n SOC SEC I TAX ID# <br /> 6tif rn i.r (rh �CIkfK FG qtr cl C0' <br /> Owner Home Address DRIVER'S LICENSE# (} I r <br /> City S, /7 STATE Fzu, <br /> t ( I Q <br /> Owner Mailing Address <br /> Mailing Address City 51 n r h t State( Zip 0/ <br /> 2 �f G0 <br /> CORPORATION IN INDIVIDUAL❑ PARTNERSHIP❑ FED AGENCY❑ OTHER❑ <br /> FACILITY FILE <br /> FACILITY ID# CROSS' <br /> REF ID# ACCOUNT ID# '" 114y# •",. <br /> COMPLETE THEFOLLOWING BUSINESS/FACILITY/ SITE INFORMATION: <br /> Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DIVISION 7 YES Ia NO ❑ <br /> Is this an EXISTING Business LOCATION but a NEW TYPE of regulated Business T YES ❑ NO <br /> BUSINESS/FACILITYISITE NAME <br /> SITE ADDRESS j f U S ;,/ Ins T t r tti "` SUITE# BUSINESSPHONE (�Q pT�>0 2- <br /> Y � fQ-'s IL , ��_"Tlltn- /'yl �Z �w�n u� �;•r�-,iniTl // (7 <br /> CITY }- STATE zip a <br /> Ndc,r Sf�r� /L1.� Z/l /SZIS <br /> BOARD OF SUPERVISOR _ I .. ( LOCATION CODE.(.,, . I,KEY1_„ ( -..._:...,._._.._ I h,_,,�2_ ',.:. <br /> ,.,,..w.,.....�. . ._ 3.., ..�...._.,_.,_._._., <br /> Mailing Address ifD/FFERENTfrom FacilityAddress Attention: or Care Of(optional) <br /> J <br /> Mailing Address City STATE ZIP <br /> SIC CODE APN# COMMENT: <br /> THIRD PARTY BILLING INFO: Complete if Billing Party is different from Property Owner or Facility Operator identified above. <br /> BUSINESS NAME ;� Attention:orCare Of (optional) <br /> Mailing Address 6 t r f N( L r t C PHONE Cz5 J / p a _12- a 0 <br /> CITY STATE }{A zip 0 09 fi1J O <br /> r,l^C Ur (�4 C l JrJ <br /> 7Ac7, AVORess for fees and charges OWNER FACILITY/BUSINESSARTY BILLING <br /> MILLING AND CONIPI.I,%N(7E ACKNOR'I.E1)(TIENT: ],the undersigned Applicant,certify that 1 am the(honer,Operator,or authorized. ,enlof thl - and 1 acknowledge that all <br /> PER)1IT FEF_1',PEVAi.7-1LC,ENF0RCF_'.51ENT C11ARGLV and/or I/0URI.YC11ARQEY associated with this operation will be billed to lite at the address identified above as the ACCOUNTADDRECS <br /> for this site. 1 also certify that all information provided on this application is true and correct;and that all regulated activities will be performed in accordance with all applicable SAN <br /> JOAQUIN COUNTY Ordinance Codes and/or Standards and STATE and/or FEDERAL.Laws and Regulations. As the undersigned owner,operator,or agent of the property located at the <br /> above facility/site address, 1 hereby authorize the release of any and all results and environmental assessment information to SAN JOAQUIN COUNTY ENVIRONMENTAL <br /> I IEALTII DIVISION as soon as it is available and at the same time it is provided to nae or nay representative. <br /> PLEASE PRINT <br /> APPLICANT NAME " SIGNATURE C <br /> inti c�� eIN <br /> TITLE DRIVER'S LICEN # job <br /> / <br /> L <br /> LCO <br /> Approved By Date Accounting Office Processing Completed"By Dater F <br />