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11-10-1999 2:d3PM Fr?C)M P. 2
<br /> •'!�'J r' S. � f�s�diaE4�K' �� '�iR _
<br /> GREEN FORM
<br /> DATE MASTER FILE RECORD INFORMATION "MFR"
<br /> SHwDED AREAS FOR RHD VSE ONLY F I UNIT Iv
<br /> OWNER FILE
<br /> COMPLETETHEFOLLOW/NG PROPERTY OWNER /NFORMAT(ON: CHECKrF OWNER CURRfNTLYONFILEW1rrEHD
<br /> PROPERTY ���� �dr�e I PHONE
<br /> OWNER NAME s
<br /> RIO MJ les(
<br /> BUSINESS NAME Co 0. `-b Soc SEc 1 TAX ID# 5"y -7 — $y_-2,2G
<br /> Owner Home AddressLI 1 S" C �L A DRIVER'S LICENSE# t*O� 3 t/ 12—
<br /> City —�-(, AC V STATE r /� ZIP 7S 3/ -2 (p
<br /> Owner Meiling Address
<br /> Mailing Address City .S"An Stats Zip
<br /> TYPF QF
<br /> CORPORATION Ej INDIVIDUAL PARTNERSHIP FED AGENCY OTHER
<br /> FACILITY FILE
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<br /> COMPLETETHEFOLLOW/NG BUSINESS I FACILITY I SITE INFORMATION.-
<br /> Is
<br /> NFORMATION:Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DIVISION? YES NO ❑
<br /> Is this an EXISTING Business LOCATION but a NEw TYPE Of regulated Business? YES ❑ NO ❑
<br /> BUSINESsIFACILITYISITE NAME C/� /r
<br /> SITE ADDRESS [' ^ /^� M`
<br /> SUITE tl BUSINESS PHONE
<br /> CITY J r� STATE ZIP
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<br /> 1 ✓, ,.I. 6
<br /> Mailing Address/f DIFFERENTfro✓n Facll/tyAddress Attention: or Care Of(optional)
<br /> Mailing Address City STATE ZIP
<br /> "A
<br /> SIC CODE' .. . . ... .,,,. ., PN'#
<br /> s COMMENT ,!�. ;,-;.. r.' i.. t •.:'•.�,:;:.. ` "'..•;.•;.
<br /> THIRD PARTY BILLING INFO: Complete if Billing Party is different from Property Owner orFacility Operator identiriedabove.
<br /> Attention: orCa a Of (optio alJ
<br /> BUSINESS NAME WCs-( (�� tJ frlr-�Al J+M tot,�T— ot`%-JA 't,
<br /> Mailing Address NPHONE _
<br /> .S J �., �1
<br /> CITY S q J r"'&A C STATE C ZIP 4 Y IO C/
<br /> AGCPUNTAQQ-&F-$.S for fees and charges OWNER FACILITY/BUSINESS THIRD PARTY BILLING
<br /> BILLING AND COMPLIANCE ACKNOWLEDGMENT: 1,the undersigned Applicant,certify that 1 am the Owner.Operator,or Aurhori;ed Agent of this Rusirim,Find I ucknowledre that all
<br /> Av"IT Fees,PF1VAr.nr_c,FNFoRCrvE,i CHARGES and/or HOURLY C11ARGB[associated with this operation will be billed to me at the address identified above a9 the ACY'iPrNTAPIKEtS
<br /> for this site. 1 also certify that all information provided on this application is true and correct.and that all regulated activities will be performed in accordance with all applicable SAN
<br /> JOAQUTN COUNTY Ordinance Codes and/or Standards and S A-iK and/or FrD1ERAL haws and Regulations. As the undersigned owner,operator,or agent of the property located at the
<br /> above facility/site address, I hereby authorize the release of any and all results end environmental assessment information to SAN JOAQUIN COUI`TY ENVIRONMENTAL.
<br /> HEALTH DIVISION as soon as it is Available and at the same time it is provided to me or my representative.
<br /> PLEASE PRINT (� n x/�� �1
<br /> APPLICANT NAME Ia�,,,'r M t)r�'V � SIGNATURE t�(�JV/��+../t I, ^! J
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<br /> TITLE Cc. nA ^W rJ n G V— DRIVER'S LICENSE 0
<br /> C(O J /" ��tIW pg� 5p (PHOTOCOPY "RFD)
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