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A a San Join County Environmental Health ftartment <br /> GREEN FORM <br /> °ArE MASTER FILE RECORD INFORMATION "MFR" <br /> cuencneoaec cno Fun uanwv OWNER ID# CASE UNIT IV <br /> OW 000 <br /> OWNER FILE <br /> COMPLETE TNEFOLLowNG PROPERTY OWNER INFORafa TION: nn / cHecKrF OWNER CuRgeNnroNFrl.EimrrH END Ll <br /> PROPERTY OWNER NAME / C e ,rN rt PHONE 2Ue� <br /> PK€sfp C First MI Last T <br /> BUSINESS NAME SOC SEC/T"ID# <br /> SI `6cKjA; era renIfvot r .s <br /> p.4r iZiV 2R <br /> Owner Home Address DRIVER'S LRYNSE# <br /> city STATE ZIP <br /> Owner Mailing Address 1176 AJ. g rL o A ID MJ .Y"V <br /> Mailing Address City 'Fd CK 7-6 AJ Sate C� Zip o/S 2a <br /> T TIG(IWNFRSHIY <br /> CORPORATION INDMDUAL❑ PARTNERSHIP❑ FEDAGENCY❑ OTHER❑ <br /> _ FACILITY FILE <br /> FAC[rry ID# OD 5 9 CROSS REF ID# ACCOUNT ID#N' l V 3 ZQ D INv# ((b L <br /> l o <br /> COMPLELEMEFOLL0147NG BUSINESS TE <br /> Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ Nolo, <br /> Is this an E)aSTING Business LOCATION but a NEW TYPE of regulated Business? YFs ❑ No <br /> BuslNEss/FA NAME C-AtZOIN4L �'1 AW; (2(2 L(Ze�fr/h/G <br /> SITE ADDRESS 'T SURE# BUSINESS PHONE <br /> N ,!} —_700' n/a2.T/k or (Nf62SQc7(.N o[= co1Kp/NRL /1✓�s. <br /> Cm sr-oc rbl✓ eon/ fER STATg 21P So�O' <br /> 601- <br /> BOARD OF SUPERVISOR DIsIRICT LOCATION CODE KEPI KEY2 <br /> Mailing Address if DIFFEREN T from Fad/ityAoom" Attention:or Care Of(option/J <br /> Mailing Address City STATE ZIP <br /> SIC CODE APN# COMMENT: <br /> THIRD PARTY BILLING INFO: Comp/ete/f Billing Party is different from Property Owner or Facility Operator identified above. <br /> BUSINESS NAME Attention:orCare Of (optional) <br /> FA,012�iL. /}SSacl /hT�P IUC. <br /> Mailing Address 3000 6,y PL4Rr YL DA. 4i-5- PHONE l6 -rGS?_ 160 <br /> c" S-NcitA-Mr�N7'o !;k 95 7 <br /> AccauitTAaaaw for fees and charges OWNER FACILITY/BUSINESS THIRD PARTY BILLING <br /> R TND AND rnmmlANrR ArKNOWr.FDOMFNT: L the undersigned Applicant,certify that 1 am the Owner,Operator,or Authorized Agent of this Business,and I acknowledge that all P£RMIT FEEv, <br /> PENALnET,ENR)RC'EMENTCnARGES end/or ROURLTCHARCE.rassociated with this operation will he billed tome at the address identified above as the AcCOLWADnarcc for this site. 1 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 DEPARTM T as so a available and at the same dme it is <br /> provided to me or my representative. <br /> APPLICANT NAME �L.µlu C(4UVLc(}((,L_PIEA�PR1� SIGNATURE <br /> TITLE $J r(G /' �'` DRIVER'S LICENSE# <br /> V cV�O Gt rI (PHOTOCOPY REQUIRED) <br /> APProved BY Date Accounting Office Processing Completed By Date v <br /> jj <br /> 29-02-002 April 25,2003 <br />