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si _I <br /> San Joaquin County Environmental Health Department <br /> GREEN FORM <br /> DATE 0230.E Oq, MASTER FILE RECORD INFORMATION "MFR" <br /> OWNERID# CASE# UNIT IV <br /> OWHOt FILE <br /> COMPLETE THEFOLLOWING PROPERTYWNER INFORMATION: ClaEarTI, OWNER CORREAFr,o, ,r TrH END <br /> PRDPERWOWNERNAME PNONE <br /> First Mf Last <br /> BuspEss NAMEI <br /> ' ' ra SDCSK/TAXID# <br /> Owner Hoping Address�'L �.\ 1 TD. DRIVER'SLICENSE# <br /> lAJ STATE ZIP <br /> Owner Mailing Acidness <br /> Mailing Address Gly State Tap <br /> CORPDRATION❑ INDwmuAL❑ PARTNERSHIP El FED AGENCY❑ OfMERf[.I� <br /> FACILITY FILE <br /> FACILITY ID# CROSS REP ID# ACCOUNT ID# IMY# <br /> COMPLEIfFTHEFOLLONTNGNF R A N' �l <br /> Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ No,Eat <br /> Is this an E7aSTING Business LOCATION but a NEW TYPE of regulated Business? YEs ❑ No� <br /> BUSINESS/FACILTIY/SITENAME ^ -A fa <br /> SITE ADORER //// (1,/ SUEIE# BDSDIESSPl10NE�'t^l 4Uk <br /> CTI, �f! yr STATE ZIP <br /> BOARDOf SUPERVISOR DISTRICT ✓` LorAnoN CODE KEr1 KEv2 <br /> Mailing Address WDIFFERENTlawH FadlityAlob5mssr Attention:or Care Of(opooml) <br /> Mailing Address City STATE ZIP <br /> APN <br /> SIC CODE # COMMENT: <br /> THIRD PARTY BILLING INFO: Complete if Billing Party is differentfrom Property Owner or Facility Operator identified above. <br /> BUSINESS NAaR 0011 ) � Attention:ov-Care Of (options() <br /> Mailing Address t PHONE <br /> Cm' ) ib 1 STATE C A <br /> v^ ZIP <br /> Aa ^vr•^^^K�for fees and charges OWNER FACILITY/BUSINESS l' THIRD PARTY BILLING <br /> Bn isen AND COME,1ANCE A PNNOWLEDGMENT: 1,the undersigned Applicant,certify that I am the Owner,Operator,or Authorized Agent of this Business,and I acknowledge that all IRE"IT FEES, <br /> PENALTIES,ENFORCEMENT CHANGES and/or HOURLYCHARO£5'associated with this operation will be billed to me at the address identified above es the 4.vATAnnncce for This site. 19190 certify that <br /> all 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 located at the above facilitylsite addreas,i hereby authorae the release of <br /> any and all results and environmental assessment information to SAN JOAQUIfs COUNTY ENVIRONMENTAL HEALTH DEPARp s noon as i is available and at the same time it is <br /> provMed to me or my representative. I_— rL� / <br /> APPLIGNfl a....i n.111'1P 1 1 P7Z P SIGNATVR J <br /> TITLE I I J Of ,L I(-)(, <br /> r DRIVER'S LICENSE# <br /> T}r 1 r A �\� fPHoTOCOPY REQUIRED) <br /> Appmve0 By��I���"`l Date Accounting Office Processing Completed By Date <br /> 29-02-002 April 25.3003 <br />