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<br /> J. quin';County:Environmental. , eq' ), epartment .�: x ...... x
<br /> �•� GREEN FORM
<br /> DATE MASTER FILE RECORD INFORMATION 1 MFR"
<br /> q:OWNERId# r.- ,3- t '"fi j r " CASE# _ tixs - ria -, UNIT IV
<br /> .��-�a`'�3b :.i�w7E.,^. ',s n,�"ti�-r,. .•fi.:�' � t„ir���_ g7'°r .�..;? _ ,Sr.ja., -,&Nx.,.'��
<br /> OWNER FILE
<br /> COMPLmTHEFOLLOWINGPROPERTY OWNER INFORMATION: !,k CHECICIF OWNER CURRENTIYOMFILEWTmEHD
<br /> PROPERTY OWNER PHONE
<br /> NAME
<br /> !- First M1 Iasi {}
<br /> t �
<br /> BUSINESS NAME f `'y� 'j�rr', Soc SEc/TAx ID#
<br /> Owner Horne Address ii DRIVER'S LICENSE#
<br /> City STATE ZIP
<br /> I II 'i
<br /> Owner Mailing Address I
<br /> Mailing Address City /1 { StateC Zip X533 d
<br /> r'llO W106T1nN 1 I T�11'1Tlinrrwr n Owonacoeuro F1 12 tl FFn Bf�Nry�I fl*uee{..f
<br /> i
<br /> ° 7 i r r ry hi t F i A INY# # rFeJ I
<br /> FACILITY ID# .'b r: -:.,c-: rCA055 REF.Id# -.2r d ,s.`�A
<br /> 7Lhis
<br /> Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENTd YES ❑ No ❑
<br /> STING Business LocATioN but a NEW TYPE of regulated Business? �? Yes ❑ No ❑
<br /> BUSINESS/FA LITY/ ITE AME I�
<br /> SITE AoDREss SUITE# BUSINESS PHONE
<br /> 66 L, D �-5
<br /> Cm � STATE ZIP
<br /> 14
<br /> • Y
<br /> TI i1rEr�
<br /> l ARD OF StiPEttvssoa DISTRICTc I LixA ON CODE I r S.a.'
<br /> atc'es.rr....<._. a.-_LIv f.h_ n.. ,ri ,.: ,-4r'-iP�d,r.,;.I &i._,n�
<br /> Mailing Address ffDrFFERFNrhom Facility Address j Attention:or Care Of( bona!)
<br /> Mailing Address City 3+ STATE LP
<br /> SIC-CODE t 1k a. b e j r {a f 8 W g
<br /> APy" is w 7 rr ;E i
<br /> : N*i... .S.;.. Fi.�vux..,�� i�.'.. `:,rt•.,.vti", ..COMMENT'-...-:_"� .v«a. A.�'a F..r";,�'.,rte:.,,. ±' sK.. iG,7r t_ tZ.` +.'„ e. i' ,. _�,�xit:
<br /> THIRD PARTY BILLING INFO: Complete if Billing Party is diferentfmm Property Owner torFacility Operator identified above.
<br /> BUSINESS NAME } Attention:or Care of (Opfional)
<br /> Mailing Address !' PHONE
<br /> - CITY STATE ZTP -
<br /> } =QMNT 4QQ9ECf for fees and charges 11
<br /> g OWNER FACILITYlBUS[NESS p' THIRD PARTY BILLING
<br /> I t
<br /> n.t,t�(7 ANh I•fl.V rL[4Nt'F*ArKN04VISDC\IENT; 1,the undersigned Applicant,certify that I am the Owner,Operator,or Authari¢ed Agent of this Business,and I acknowledge Iha1 all PERMIT FCs,
<br /> PENALTIES,CNFaRCEMENTC1fARGES and/or 110URLrCHARGES associated wlth this operation will be billed 10 me al thea ddress
<br /> headdress Identirted above as the for this sile. I also errtiry that all
<br /> 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 localed at the above facility/site addrps,1 hereby authorize the retease of
<br /> any and all results and environmental assessment information to SAN JOAQUIN COUNTY ENVIRONMENTAL RF-ALT14 DEPARTMENT as soon as it is available and at the same'time itis.
<br /> ti provided to me or my representative.
<br /> PLEASE PRINT - I -
<br /> APPLICANT NAME SIGNATURE
<br /> TITLE _. DRIVER'S LICENSE#
<br /> .. ., (PHOTOCOPY REOUIRED)
<br /> approved By,;{.,. # yDabe ,-k � 4.: nom'ilk A000urTttng.OfBae ProcPsstng Gomkk pleted
<br /> J1 • Ii i�
<br /> { t�
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