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'1k07/2B/2004 15:09 209468. 3 FIFTH FLOOR PAGE 04 <br /> San Join.County Environmental Health DeSment' <br /> GREEN FORM <br /> DATE MASTER FILE RECORD INFORMATION '"MFR*0' <br /> SF1Ancn eor:ec crw FHA Itea t1N1 V OWNER ID# D� 6n 1/y.;'— CASE 0 UNIT I V <br /> OWNER FILE <br /> .OMPLETETwFogLoWiNGPROPERTY OWNER INFORMAlZ'ON; 0iEL7CIF-OWNER CURREMcv�OI/rF'rFwrrH END <br /> PROPERTY OwNERNAME L l /— PHONE G � <br /> .�..A.-, <br /> 1 Irst MI / Last <br /> BUSINt:SS NAnIElrA 1! f 666:r J I�6 F�US. SOC SEC/TAY XD.# <br /> owner Nome Address 1�ezz <br /> DRriERcs LICENSE 0 <br /> City STAT <br /> r <br /> owner Mailing Address <br /> Meiling Address City c N �i C> ZP <br /> TVPG r1C�LfN/4Wm <br /> CORPORATION 11 3NDMDUAI PAPMBE S1IPO FPDAGENCY❑ 0T14EK <br /> FACILITY FILE <br /> FACRMY ID V /q/1 l��J / CROSS REF ID# ACCOUNT ID ak `' 3 IMV# <br /> M&Al M THE Wl/OW NG RI SEbl ' FACILITY f SITE LNFORMaTI'DAfr <br /> Is this a NEW Business Loc—ON not previously nagulal: d by the ENVIRONMENTAL HEALTH DEPARTMENT? YES Q No <br /> Is this an EItISRNG Business LOcnTioN but a NEW TYPE of regulated Business? YES E3 No <br /> ff <br /> Busv&ss/FAcRm/STTE NAME i1. /P u✓ W AV—'�' <br /> SITE ADDRE55 � `,- �}.J^�.�!/ SU ITE# BUSiNEW PHDf 1E <br /> Cir t� �1` SrarE ` ZtP <br /> V <br /> BOAgD DP S MERVISOR DISTPICrIF I LOCATnota Goof KEY1 KE Y2 <br /> Mailing Address ffDI7Eff IVrft*W F.?&fiyAddleff Atbwtion:or Care Of(vptfunal) <br /> Mailing Address City ZIP <br /> 7 0') w�T— �—(� S�- L✓ I '`" <br /> sic Cox -- APN .T �6�Z3 __0 E CottMENr: <br /> IRD ARTY ILLING INFO; Complete if Billing Party iS dlifferent from Property Owner or Facility Operator identit!ed at ave <br /> AtbentfoR.orCzre Of (oplyortal) <br /> MailingAddtm ),1 6-TV'r7i`��sLj�'(�191� PHONe <br /> CITY C�. 1/l1 STATr; t ZIP <br /> AQmmom4pasm for fees and charges OWNER FACIUTYiBUSINESS THIRD DARTY 13ILL1140 <br /> 1,the uodeniLoed Applicant,cerdfy tint 1 am the owner,Operator,or Aurhdri4ed Agent of 11ti6 Business,and I ackmwled:e that all PERecrrFAM, <br /> ev�LTIE5,ENFORC:HMMW 011ACPS and/or fIOCIRcrCHAR=a7.smiated with This operation will be b;Iled to nx at the address identirird above as Ilte ArmrnvrAnoxf=ss(or this kite- f also ttrtify that an <br /> formation proAded on Ws appliondon is true and correct;and that all regulated aedvlttcs will bo performed in accordance With aV apPlkabic SAN JoAQum CounTy Ordinance Codes and/or <br /> andards and STATE and/or FWEPAL Laws and Regulations- As the undeniEned owner,operator,or agent of the property locntcd at the abay,facilitylsite address,1 bcreb,nuehorire the release of <br /> q and all reswlh and environmental assessment Information to SAA 4OAQIIIN COUNTY ENVIRONMENTAL HEALTH DEPARTNIEV"as soon as It Is available m,d at the same time it is <br /> r6vided to me or cry repretenta ve. p — <br /> /APPLICANT NAME IV) ll(q•v1 i T1.�e P�EPRINr th/[ SIGNATURE <br /> TITLE14 DOPY ) <br /> App—ed BY Dat t Aeeotenting Offim Prvexssing COmpleDed BY Dace Y <br /> -02-002 Apnl 25,2003 <br />