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San Jc-quin County Environmental Health ^apartment <br /> / D _ GREEN FORM <br /> MASTER STER FILE RECORD INFORMATION ��IN1PR" <br /> cwancn aocac FnR FHn ncF ONS v OWNER ID# TC7AE UNIT IV <br /> OWNER FILE <br /> COMPLETE THEFOLLOWING PROPERTY OWNER INFORMATI H 916, WNE�Cb1;;. 2ZLEwrTH EHD <br /> PROPERTY OWNER NAME /J e / / C, �� C `C PHONE !`_Lj Q!? {(- <br /> Iv <br /> l` First M/ C� Last l V t C-K Ivy[ (�J�O`4-6) <br /> BUSINESS NAME SOC SEC/TAx ID 1 <br /> �.rJ i �v �✓a ,� ,C i rill c. <br /> Owner Home Address ,S C !� „/ DRIVER'S LICENSE ` <br /> city STATE C� uP <br /> Owner Mailing Address Q / <br /> Mailing Address City C� State Zip <br /> TyoFnF I Q'MFRCHTa_ / - -- -- - -- _ -CORPORATIONE(77/•�f/J 6 INDMDUAL a&- PARTNERSHIP❑ FED AGENCY❑ OTHER❑ <br /> FACILITY FILE-_ <br /> I CROSS REF ID# ACCOUNT ID# <br /> FAINV# i <br /> q <br /> FACILITY ; 6)'.��Z 3 7-:I (�OOt� s lry 1 it,9c ti <br /> Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ No>< <br /> Is this an EXISTING Business LOCATION but a NEW TYPE Of regulated Business? YES ❑ No-, <br /> BUSINEss/FAQIITY/SITE NAME <br /> SITE ADDRESS 'T !/V"✓J ! ! SUITE# BUSINESS PHONE <br /> City f ! ! I STATE Zip <br /> BOARD OF SUPERVISOR DISTRICT LOCATION CODE I ) KEY1 ISI.. KEY2 J <br /> Mailing Address tfDIFFEREArTfrom FadlityAddles s Attention:or Care Of(optional) M <br /> Mailing Address City STATE Zip b <br /> FCODE JAPN# COMMENT: to <br /> tl <br /> THIRD PARTY BILLING INFO: Completeif Billing Party is different from Property Owner or Facility Operator identified above. � <br /> BUSINESS NAME Attention:orCare Of (optional) <br /> Mailing Address PHONE <br /> CITY STATE zip <br /> ArrxTnalT dnneFac for fees and charges OWNER FACILITY/BUSINESS THIRD PARTY BILLING <br /> �r�nr <br /> Rn J.INO ANn Comps JANrE ACKNOWLEDGMENT: 1,the undersigned Applicant,certify that 1 am the Owner,Operator,or Authorized Agent of this Business,and 1 acknowledge that all PERMIT FEES, <br /> PENALTIES,ENFORCEMENT CHARGES and/Or HOURLY CHARGES associated with this operation will be billed tome at the address identified above as the Arr'O(iNT AnDRF.cc for this site. 1 also certify 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 JOAQUtN 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 facility/site 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. PLEASE PRINT <br /> APPLICANT NAME �SIGNATURE G�A tTy <br /> 16 /� �r AJ /� f,5Q=- <br /> TITLE DRIVEWS LICENSE# <br /> (PHOTOCOPY REOUIRED) <br /> APPed BY Date Accounting Office Processing Completed By �T Date \ 3S <br /> 29-02-002 April 25.2003 <br />