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.•g0.,t ..Lanmu,+..r. 1k!*?'11""Ph <br /> y <br /> «w a Hwa �San J m�County E ui tan entallealth:rartment <br /> GREEN FORM <br /> DATE MASTER FILE RECORD INFORMATION "MFR" <br /> OWNER FILE _ <br /> COMPLETE THEFOLLOWMG PROPERTY OWNER INFORMATION: 'CY/£IXFF OWNER CuaaEHnroNnzewTTNEHD ❑ <br /> PROPERTYVISOWNER /01 /� � /� Inc, PHONE <br /> NAME l//qr rlsF/ —Iri.� I/I/ , / Y /1 <br /> Final MI last <br /> BUSINESS NAME //�l1 f SOc SEC/TAx ID# <br /> Owner Home AddressDRIvEn's UceNsE# <br /> City 7iv /I I l.—CA <br /> Mailing <br /> — arra STA A ZIP �20 <br /> owrw Mallitp Addrts _c K ' l) ` <br /> Mailing Address City state Zip <br /> Ivor nr nWNERSHIP <br /> Mvonasnnrs❑ INnrvrnnai l7 Deetvrocure❑ Frn 8...❑ rvmro❑ <br /> At3. .:n`SLtd«. ', Gi65sREFyT6 ..,.-.. ActAUNL;IDhJR':. i. . .... + <br /> COMPLETE THEfOLLOWRIV BUSINESS I FACILITY SITE INFORMA710N. <br /> Is this a NEW Business LoaTIoN not previously regulated by the ENVfRONMENTAL HEALTH DEPARTMENT? YES ❑ No ❑ <br /> Is Nis an Exzsrlmc;Business LO TTOrr but a NEW TYPE of regulated Business 7 YES ❑ No ❑ <br /> BusINESs/FA SITE NAME <br /> SITE ADD �70/ ✓ iv tom_ Sum# BUSINESS PHONE <br /> (�ru�-�5 ��� <br /> CITY i C I� ti p ` STATE/L ZIP q C�70-F <br /> If e�tI �SD?ERY1;dN„MD _ U �,/ I I . I i„�J� a. <br /> Mailing Address WDIFFERENThom teadlifyAddress Attention:or Cale Of(optional) <br /> .Mailing Address CRy <br /> STATE ZIP <br /> goal FIV— <br /> -THIRD PARTY BILLING INFO: Comp/e(eif Billing Party is different from Property Owner or Facility Operator idenVAed above. <br /> BUSINESS NAME Attention:orCam Of (optional) <br /> Mailing Address PHONE <br /> CITY - STATE LP <br /> AcroLevrennucee for fees and charges OWNER FACILITYIBUSINESS THIRD PARTY BILLING <br /> It the undersigned Applicant,certify that 1 am the Owner,Operator,or Authorized Agent of lids Business,and 1 acknowledge that all PERMIT FEES, <br /> PENALTIES,ENFORCEMENT CHARGES and/or 110URLYCHARGES associated with this operation will be billed tome at the address identified above as the ArrnUNTALDRicc for this site. I also cerdfy that all <br /> information provided on this application Is true amt correct{ and that all regulated activities will be performed In accordance with all applicable SAN JOAQUIN COUNry Ordinance Coles 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/ske address,I hereby authorice the release of <br /> any and all mnWb and environmental assessment informadon to SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT vs soon as it is available and at the some that,it is <br /> provided to me or my representative. '- <br /> _. ..-- PIFASE PRINr �.� <br /> APPLICANTNAME r SIGNATURE <br /> I— <br /> i <br /> TITLE NcI ` DRIVER'S LICENSE# <br /> (PHOTOCOPY REQUIRED) <br /> D <br /> ��PP_!n�4!,8 ;ypa� _____. ._._-_ AC_o111wF nd1�q.OflSce�pfdcessing.CdfRP�etet�l3. D <br /> a <br />