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San iquin County-Environmental HeaAepartment <br /> OnrE MASTER FILE RECORD INFORMATION TTMFR" GREEN FORM <br /> v glag r� <br /> OWNER ID# GSE# .. <br /> UNIT IV <br /> OWNER FILE <br /> COMPLETE THE FOIL 0WINGPROPERTY OWNER INFORMATION; CNECKrF OWNER CURRrNnyONFrLEWmIEHD ❑ <br /> PROPERTY OWNER /Il�C.60 <br /> Uj /J�I <br /> NAME 60/ ti JI � S l PHONE l l I ✓ � � / <br /> First MI last <br /> BUSINESS NAME / /1 + I SOC SEC/TU ID# <br /> vu <br /> Owner Home Address <br /> DRNER'S LICENSE# <br /> City L C� .Ty.v IC — C� Ar(• STA (— <br /> A ZIP y� 1—26) <br /> Owner Malliip pddreAs <br /> Mailing Address City <br /> Zip <br /> TYoc nc— nva_3� <br /> rn.,no.. .nu n Too...... F1 Dan,wrRcu,n n P.M1 a.:rs,..�n <br /> on <br /> FILE <br /> ..FAauTV ID#— ff CROSS REF ID# a, AIXpuNT ID# <br /> Is this a NEw Business LounoN not Previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ No ❑ <br /> Is this an E%ISfING Business LOCATION but a NEW TYPE of regulated Business 4 YES ❑ No ❑ <br /> BB$INESS/FAatlq/$ITE NAME �? <br /> SITE ADO � <br /> /n c SUFE# BUSINESS PHONE <br /> CITY I C `V� STATE Zip A 70j— <br /> IIBPARI)OF SUPERVIson DnTnICTx ,I-;. ,I LouTION CIwE,.. I ? KEY1 t + i _l <br /> ' ..y —:1.— <br /> M a i I i ng Add ress WDIFFERENr ftm <br /> , . ,MailingAddressWDIFFERENrlmm Faa/ityAddresr Attention.or Care Of(optional) r <br /> Mailing Address City STATE LP <br /> .:.SIC CODE CONMurn Wry <br /> -THIRD PARTY BILLING INFO: Completed Billing Party is different from Property Owner or Facility Operator identified above. <br /> BUSINESS NAME Attention:ot-Care Of (optional) <br /> Mailing Address <br /> PHONE <br /> cm <br /> STATE ZIP <br /> ACCQM TAn RE—ss for fees and charges OWNER FACILITYIRUSINESS <br /> THIRD PARTY KILLING <br /> BILLING Arvn COMPT 1ANCE ArKNOW1 EnGNIENT: 1,The undersigned Applicant,certify Ilial 1 am the Owner,Operator,or Authorized Agent of But Business,and 1 acknowledge that all PFRAnr FEET, <br /> PENALTIES,ENFORC'ENENTCRARGES and/or 1101/RLYGIARGES associated with this operation will be billed tow at the address identified above as Ibe AFFORNr AODRFee for This site. I also certify That all <br /> informadon 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 undersignul owner,operator,or agent of the property located at the above facility/site address,I hereby authorize the release of <br /> any and all result,and environmental assessment Information to SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon As it is available and at the same time it is <br /> provided to me or my representative. <br /> _ PLEASE PRINT <br /> APPLICANT NAME (/ I / 1 SIGNATURE <br /> I �fY L�—r;r^—+ <br /> I I � <br /> TITLE '� �j vICI [ Q DRIVER'S LICENSE# <br /> fEHOT000PY REOUIREDI <br /> Approped By _ >Date .ti Aaounting OfficeProoessing Completed By <br /> rR <br />