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San fAquin County Environmental Health0partment <br /> DA j� //JGREENFORM <br /> MASTER FILE RECORD INFORMATION "MFR" <br /> SHADED AREAS FOR END USE ONLY OVINERI(* CASEM UNIT IV <br /> OWNER FILE <br /> COMPLETE THE FOLLO GPR0PERTY OWNER INFORAFAT/ON.' CHEcKfr OWNER CURRIR rzYONRLEWM EHD� <br /> PROPERTYOWNERNAME �. �� y- PHONE <br /> Ir First MI Last <br /> BuemEss NAME rj ,Nf / / am SEC I T.ID f/J./O <br /> OlNnerffane Addnes �f�Qb.r /�. ��[— l/.,. �^' ^rM`.t�`I DRIVER'S LICENSEN�/ <br /> / f� Z� <br /> .r <br /> ST <br /> Clly �^/ <br /> Owner Melling Addreas-P, V <br /> Malfing Addresa City � V v mate Z ...J3 <br /> CORPORATION F-1 INDIVIDIIAL❑ PARTNERSHIP El FED AAENOY❑ OTHER <br /> FACILITY FILE <br /> FACILITY IDR O O 88 REF IDM ACCOUNT IDM /� �^ INV# <br /> COMPLETE THEFOLLoww BUSINESS FACILITY SITE INFORMA71oN.' VYl`W^ U <br /> Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPT.? YES ❑ No ❑ <br /> Is this an EYJSTING Business LOCATION IRR a NEW TYPE of Business? YES ❑ No ❑ <br /> BuSINEBSIFACRTY/SITE NAME <br /> SREADDRES9 y� &IITEM BUSH r� <br /> („ €-1 O <br /> Cl . / STATfr ',j ZI�� _ <br /> /V '--7' Q <br /> BDARDOFSWERVISORDISTRICT LOCATION CODE KEH HEY2 I r! <br /> MaMng Address NO/FFERENTIlom FeaftAddr AfMrtlon:Or Can Or(000naU <br /> IN <br /> Melling Address Chy —II STATE ZIP V <br /> SIC CODE APN# I COMMENT: — —] <br /> THIRD PARTY BILLING INFO: Complete i£Billing Party is different from Property Owner or Facility Operator identified above. <br /> BUSINESS NAME AlEsrdbn.orCen Of fdPaDrraq <br /> Maillne Address PHONE <br /> STATE zip <br /> Cm <br /> AQoouO'A&a& s for fees and charges OWNER FAciuTYIBUSINESS THIRD PARTY BILLING <br /> BILLING AND COMPLIANct;AcNNOWLEDCMENT: I,the undersigned Applicant,certify that I am the Owner,Operator,or Authorized Agent of this Business,and!acknowledge that all Pra,U1F FEES, <br /> PIiN9LTH;A,Est 0R(,,AIFN7 C),AB(]ES and/or HOURLY CINHO/!S associated with this operation will be billed tome at the address identified above as the A((OUNTADDRISS for this site. I also 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 LOUNa'Y Ordinance Codes and/or <br /> Standards and SIAU:and/or Ftipmm.Laws and Regulations. As the undersigned owner,operator,or agent of the property located at the above f ecilitylsile address,I hereby authorize the release of <br /> any and all results and environmental assessment information to SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my representative. <br /> PLEASE PRINT SIGNATURE <br /> APPLICANT NAME L <br /> TIRE ../ DRIVER'S L CENSEM <br /> ?1&4r�r P o o u1RED I <br /> Approved By �i Deb Ammarding CMee Proomins;Cwnpbled B Deb I <br /> 11)02 I0,12 07 MASTER HLE It ECOR D-GSEEN <br />