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San Jc, '�jin County Environmental Health-apartment <br /> 0 <br /> atE MASTER FILE RECORD INFORMATION "MFR"' <br /> GREEN FORM <br /> �`{- euenen eocec cnoF OWNER ID# CASE# UNIT IV <br /> OWNER FILE <br /> COMPLETE THEFOLtowNG PROPERTY OWNER INFORMATION: CNearF OWNER CVRRENn YDNF W EHD <br /> PROPERTY OWNER NAME L <br /> PHONE 209.948.5566 <br /> x <br /> First MI rLast <br /> BUSINESSNAME y.Yl/� $pp$EC/ TA%IO# <br /> t 94-1563999 <br /> Owner Home Address DRIVER'sum+SE# SO496264 <br /> City <br /> STATE YIP <br /> Owner Mailing Address <br /> Mailing Address City / J <br /> dc- State Zip 9,fs�a S <br /> TVPF nc nwucwcN e <br /> y <br /> CORPORATION❑ INDIVIDUAL❑ PARTNERSHIPFee AGENCY El - OMM14 <br /> FACILITY FILE <br /> FACILITY I D# Caoss REF I D# ACCOUNT I D# I NV# I <br /> OMPLETET EFOLLOWING au s I N Fss i EACILITY1 SITEINFoRmATioly, Y <br /> Isthis a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YESA No ❑ 1 <br /> Isthis an EXI STING Business LOCATION but a NEW TYPE of regulated Business? YES ❑ No ❑ <br /> BusI NESS/FACT U TY/SI TE NAME COY \ \ ��ta �\De•t�L �rGgN$1 (� /'i�%'� <br /> SITEADDRESS Ito LO l SUITE# 103 NESS PHONE <br /> R10/ . W <br /> CITY STATE -LP <br /> CA SCaG L Q <br /> /$Ti0'S <br /> BOARD OF$UPFRVI SOR DI STRI Cr IACATI ON CODE KEY'I IKEy2 <br /> Mailing Address ifDIFFERENTfrom FadlityAddress Attention:or Care Of(optionaQ y <br /> 3 C. Lir-j Q S A 5T 1'Z--t <br /> Mailing Address City STDy� STATER Zip d <br /> �/ <br /> $IC CODE APN# O COMMENT: - <br /> r I <br /> THIRD PARTY 131LLINO INFO: Complete if Billing Party _isdifferent from Property Owner or Facility Operator idendfied above. <br /> Bust NESS NAME. Attention:orCare Of (optional) <br /> -. ells. <br /> Mailing Address PHONE <br /> • ._... ' � .,ter <br /> QTY STATE zips. <br /> nw•�for fees and charges OWNER FACILITY/BUSINESS THIRD PARTY BILLING <br /> Bit I Nr,AN,Come, ANCF ACKNOW EMIR ENT: 1,the undersigned Applicant,arlity that I am the Owner,Operator,or Authorized Aged of this Burnes,antli acknowledge that all PERM IT FEES, <br /> PENALTIE$ENFORCEMENT CHARGES and/GT HOl1RLYCHARGES aSOdated with this Operatim will be billed to meal the addressldetiffed aboveaslheAmxiNTADDRFce forthisate. Ialsooetifythat <br /> all information provided can thisapplication Istrueand oxre :and that all regulated activilieswill beperformed in aanrdancewith all applicable oUIN CouenY Ordinance Code;and/or <br /> Standardswcl STATE and/or FEDERAL Lawsand Regulations Astheundersgned owne-,kprator,or ager of the property located at theabovefail Wei �d hereby authorizethe rdof <br /> any and all results anti Environmental amasnent information to SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as tis ailabl d at the same time it is <br /> provided to meor my representative PLEAS PRINT <br /> APPLI CANT NAME SIGNATURE f <br /> �Dnna �t.15a � <br /> TITLE. DRIVER'SLICENSE# SO496264 <br /> V / /"t "l (� L (PHOTOCOW REOUI REDI <br /> Approved BY IFA Office Processing Completed By Date <br /> 2&02-002 April 25,2003 - - 1 <br />