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<br /> GREEN FORM
<br /> DATE i 1, a000 MASTER FILE RECORD INFORMATION "MFR"
<br /> UNIT IV
<br /> S�AQ,ED APCAF rOJ1fCIayliKRntt
<br /> OWNER FILE
<br /> COMPLETETHEFOLLOW/NG PROPERTY OWNER INFORMATION: CHECK/F OWNER CuaaeNrcroNFILE wirHEHD
<br /> PROPERTY /� \ PhoNE �( q _7
<br /> OwmeR NAME /' 1 O/PO/a 11 \J / c,,,
<br /> WSI M/ rsl
<br /> BuSiNEssNAME C�!h �CJ�r ( ✓ rS3 SoCSEC/TA><IDA JI-003Sy5
<br /> Owner Home Address �^7 Ze r Y" '�r "d'� '''r� DRIVER's LICENSE N
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<br /> i City ")'p S �� �M 1nr��q G� CnS �o�✓,.i� j .Jrfn{�r I ^SS�C'
<br /> STATE zip 33 L
<br /> ownri Mailing Addraas C/ Seto zip 3Mailing AddreS3 City 16 J I
<br /> J +
<br /> CORPORATION INDIVIDUAL O PARTNERSHIP❑ FED AGENCY O OTHER
<br /> FACILITY FILE
<br /> ti: x.-: !` fi�Y,✓P N7'`'.Yv''y�»kL=YR: r�LtF�:d+'e`.gy'-'1`l+:i¢; "�'Pk"�"
<br /> .y ,�:.��'{.:,y4. .'S.•: 1..`I�f �",tij(1 i '•BMs" `W '�., �, 1.,,"e ;�': Mei ,� �, .� k +�,ct.�'ai, t
<br /> t�:F'aclltT'rID'I✓:'aK{';.,i,.'��?,,•;:yiX,;�:.y%�;r.-�:tCRo�s°R F: iit r�,pr2�t. �'�L'.:.{i -.�AocouNt _ xk'•' -����:i ,..
<br /> COMPLETETHEFOLLOW/NG BUSINESS/FACILITY/ SITE INFORMATION_'
<br /> Is this 9 NEW Business LOCATION not previou3ly regulated 4y the ENVIRONMFNTAL HEALTH DIVISION? YES ❑ No
<br /> Is this an ExisTwa Business LoCATION but a NEW TYPE of regulated Business? - YES I] No
<br /> BUSINESS/FACILrrY/SITE NAME I S � �P q —1 -
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<br /> SITE ADDRESS SUITE/1 BUSINESS PHONE 1/I�
<br /> STATE /'1 LP `1
<br /> CIT]Y1y{1.��ya/ �f;��r1 /r
<br /> ��i�t�'Wr�'iV.^ Yy'�j.CKXOy�-J
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<br /> Mailing Add*res3 ifD/FFERENTfrom Fee i(YAddress Attention:or Care Of(optional)
<br /> Mailing Address City 2 S�- NPq�! STATE rL zip 3 y
<br /> ave RAP,N': COYYENT, cC � ' ` ;'+ r
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<br /> THIRD PARTY BILLING INFO: Complete if Billing Party Is different from Property Owner or Facility Operator identified above.
<br /> BUSINESS NAME �hy,/ n �� / C Attention:or Care Of (optional)
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<br /> Oh 0 -� f �N/✓.. .
<br /> Milling Addressi 1 �� r I o o ��O V. ✓ a vJw PHONE 1A�
<br /> CITY N ! J o b STATE 1IN ZIP OD 0 G a
<br /> Ac�O�r/v,LA. ggss for fees and charges OWNER FACILITY/BUSINESS THIRD PARTY BILLING
<br /> Rn.f.tnr.�Nu C nntrl.twNf.►: t C�npwt,F;t)CMr:NI: 1,the ung
<br /> emigned Applicant,certify that 1 Ant ilia(hexer,Optrulor,ur Aurharized Ageitf o 1 nErql And 1)4cknuwlcJgc(hat at,
<br /> PERAIlrFviCv, FNPO*ceAieivrCuAKr;gv with this operallon will be billet to me At lite address identified above am the.j(X'uuwrAupRFc,
<br /> for Ilds site. I alma certify lhal all hirortualiuo pruvided un this application is true and currccl;and that all regtdaled aclivitics Mill be performed in accordance with 1,11 applicable Snr
<br /> JOAQIIIN Cowrie Ordinance Codes and/or Standards and b1'ATx and/or VEDERAI.Laws and Regulations. As the undersigned owner,otleralur,or agent of the property located st Ib,
<br /> above fucilily/site addrrbs, 1 hereby authorize the release of any and all results and environmental maamsmcal Information to SAN JOAQVIN COUNIA' ENVIRONMENTAL
<br /> lIEALTII DIVISION as soon as it is available and at the same time it is provided to nit or my rcpr=cniative.
<br /> PLEASE PRINT
<br /> 7� /+
<br /> AF�PLICANT NAME �r�SO ti hC, Gd J I� SIGNATURE
<br /> DRIVER'S IJCENSt=!! I � � S 3�O 3 � I (CT)
<br /> TITLE V I ,�ec �r {Cu� SPri rr� (��?�anz•J �gP_.t ) -
<br /> J PHOTO .OW RFOI11��
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<br /> �A pro'vod'8y,.,wC,, . 'i ::•�f Date " ..::Sv1 R` :Aacountln9 0rfioaPr0003i itp Com�i�eQ B
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