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San Josin County Environmental Health Xartment <br /> OASGREEN FORM <br /> L-Z _�� MASTER FILE RECORD INFORMATION "MFR" <br /> IPa EHOUSE ONLY CABEM UNIT IV <br /> OWNER FILE <br /> COMPLETE THEFOLLOwINGPROPERTYOWNER INFORMATI)OM' CiNis arOWNERCumievvarONFALE m/EHD <br /> PROPERTY OWNER NAME sJ�'Mv; !�I /C f6H,�f�"+�`2 PHONE <br /> £P2C5Y'K 16�'c Fi sf MI Leat <br /> BURINEss NAME �(y� I —<.. n.L ^ .V LLQ[, BOCSECITAXIDS� <br /> Owner Home Addreea TL UN DRNER's LICENBEA <br /> GfYQI/III!l� - GR / 7-6lT " COZ 7 STATE <br /> Owner Mailing Address ! LCV <br /> Mailing Address City Stets zip <br /> CORPORATION❑ INDIVIDUAL❑ PARTNERSHIP FEDAGENOY❑ OTHER❑ <br /> // 1� Q1�✓�1 FACILITY FILE <br /> FACILITY IDA r Ot/1 `V 1 CROSSREFIDY .ACCOUNT ID* INV# <br /> w 3 3 52 <br /> CoMPLETETHEFottowfNG BUSINESS 1 FACILITY I SITE fNFORMAnoN.' <br /> Is this a NEW Business LOCATION notpreviously regulated by the ENVIRONMENTAL HEALTH DEPT.? YES 0 No ❑ <br /> Is this an EXISTING Business LOCATION but a NEW TYPE of regulated Business? YES ❑ No ❑ <br /> BUSINEssIFAcLRYISITENAME JRef6Al7 ._ �e,yriJ/yf/A/ZC/(}(, ( rV29 /'N. !Gy - -zzo — 6( <br /> 9REAODREBa <br /> CRY SURER BUSINESS PHONE <br /> Lp/ `/1KpLyA) (,/JS7� �LJO <br /> STATE G�. ZIP ! S hOCO <br /> BOARD OF SUPERVIBORAIBTRICr LOCATIONCODE T KEY1 KEVZ <br /> 1 <br /> Mailing Address HDIFF�E/RENTfiom FacU/tyAddress Attention:or Care Or(optional) <br /> /V 6 <br /> Mailing Address City STATE 7JP <br /> SICCODE APN# COMMENT: <br /> THIRD PARTY BILLING INFO: Complete ifBilling Party is different from Property Owner orFacility Operator idendfied above. <br /> BUSINEWNAME Atfenborr:orCam Of(epHatsf) <br /> 3udtacqu (/irAl%YQ�S N�' (AIC. —�O (7.Jn/H¢Lo 4-5x�rml p �l <br /> Melling Addrem�n�rI.?.0�,,.t/CeLf. C.l� NLO 12�C� PHONE 7ZS' r{2 " .2G ! / <br /> CRY �uwv S/ I�(I/V STATE(,. LP 7 G,�66 <br /> AggaMolam 4 for fees and charges OWNER FACILITY/BUSINESS RD PARTY BILLING <br /> StILLING AND COMPLIANCE ACa zows,EDCMEM: L the undersigned Applicant,certify that I am the Owner,Operator,or Authorized Agent of this Business,and I acka wledge that all PEKs FEES, <br /> PEwGrIEs,EfYFORCFMENTGuRGrS and/or noLw YCNAxGFs associated with this operation wg!be billed tow at the address identified above as theACCouNrADuxESt for this site. I also certify that <br /> all iuformatdun provided on this application is true and correct;and that all regulated activities will be perfo Med in accordance with all applicable SAN JOAQWN COO Ordivaoce Codes and/or <br /> Standards and STATE and/or FEDERAL Laws and Regulations As the undersigned owner,operator,or.gem of the property located at the above facility/site address,I hereby authorize the release of <br /> any and all results and eoviroemeotal assessment information to SAN JOAQUI N COUNTY ENVWONMENTAL HEALTH DEPARaoeo as it is available and time it is <br /> provided to me or my rvpresrnmdve n <br /> APPLICANT NAME �&0+w /T -a5/^/7M SIGNATURE <br /> TITLE - DRIVER'S 10E11 ---� <br /> �C �wL (PHOT OM REDI <br /> 4nnrewrM Rr nd. II Ar—Inn Omeo Prvewlne Comoleted av ( Dab {l L yl I <br />