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__.�...San-Joa uin-Couny:= ! �5 5ervlces,: :_t1�1 3�AF ►l t�iear~> u v st
<br /> GREEN FORM
<br /> DATE �� I %, P000 MSTER FILE RECORD INFORMATION "MFR" SS b�s�3�
<br /> ),,, UNIT 1V
<br /> 15
<br /> :N�oro int-s row rnLyle Pala w3v-�
<br /> � � Y FA�Pan �:. ' t<','{C{,`�
<br /> OWNER FILE ��p1�7�
<br /> •'OMOLETETHEFOLLOW/NG PROPERTY OWNER INFORMAT/ON: CMECK/F OWNER CuaaENrcro�lt�cEw/yHEHo
<br /> _
<br /> PROPERTY PHONE/ \ ' d.
<br /> OF/NER NAME
<br /> BYti1ME.S3 NAVE C SOC SEC/TA>;ID It 1
<br /> � '7 ,l-oo3SY5�,
<br /> Owner Home Address 6 s /^ �� ZG": -'' '� ` ' /"/1 DRIVER'S LICENSES /V A
<br /> city (� I STATE I FZIP 3.2
<br /> L )"S � PCI-1 73Pq
<br /> own./Mailin9 Addraas /G10 JS,,,,� L. De�e7 ��1.17 , J�✓\tJ/ Ass, I. /I
<br /> Malling Address City State zip 7
<br /> FED AGENCY C1 OTHER
<br /> CORPORATION INDIVIDUAL❑ PARTNERSHIP❑
<br /> FACILITY FILE o gas CP
<br /> r:ll�s •\_><. ;I '•yy: <'?!_., a�Kw' •.• ., r,./s,.,:\Ye: r.:ta:.:k'e`+py�t`r"'i,,,la. '1�,t ,ywn• '^, Y�p.{S�t'i:t»rA•r�':,Stl"f":t�
<br /> :ri� �: y1J1.\..
<br /> �AoeoirNt D�.
<br /> !0,4fpLETETHEFOLLOWI/VG BUSINESS/FACILITY/SITE INFORMAT/OA( /
<br /> Is this a NEW BuSinASs LOCATION not previoUsly regulated by the ENVIRONMENTAL HEALTH DIVISION? YES ❑ NO pE
<br /> Is this an EXISTING Business LOCATION but a Nkw TYPE of regulated Business? YES p No J
<br /> BuslNEss/FACILMISITE NAME r \ i
<br /> G G^ r^j
<br /> SITE ADDRESS : SUITE M BUSINESS PHONE /
<br /> 3yaa �� - i = f
<br /> CITY r� �^ STATE /} ZIP
<br /> 'tvt ir:'.:�7i tl' �' ;. """• ? °�` '�tj•ZI l ,, tir S1►I -�' ` ''r i, r :sat :4� f'" -`�
<br /> Mailing Address ifOIFFEREIVTfrom Facility Address Attention: or Cara Of(optional) l
<br /> —f T l
<br /> Mailing Address City ) RPa� !� STATE t--_ zip Z3 J i
<br /> , eJ ,
<br /> ; i gr '
<br /> s.
<br /> 251C'GooE. .'.',I . i AP.N': t Co ivt,. .
<br /> TWRD PARTY BILLING INFO: Complete/f Billing Party /s different from Property Owner or Facility Operator identified above.
<br /> BUSINESS NAME -Z) Attention: or Care Of (opllonal) r
<br /> ! G fU q 0h �hv!/Or iii^�i I L\�'//
<br /> Milling Address t _ PHONE i o _
<br /> CITY STATE 11AA ZIP o a o G
<br /> No/5� oa�
<br /> /1_GCO 1V•ZAYZQ_ggg3. for fees and charges OWNER FACILITY/BusINEsS THIRD PANTY BILLING
<br /> IIu.ITn�♦rvu t:nnfrt.lenfc ACclvowt,►:nCMF:NT': 1,the undentignod Applicant,cenify that 1 am(lie OW*Idr,Operator,urAulhurized Agenr a I ns,a l acknuwlcdgc that Y
<br /> reannrFtJ:,1'rJAJ,YIeI,F.NfURC�A/BN7C1/AhYt1'uud/Or/h1URl.YC//tHCtiti associatal with this operation Will IK billeO to rite at IIIc address identified above as the ICt'IIUNTAUPlt6
<br /> for IIJt silo 1 also certify that sill tilforntaliun pruvidtd un this application is true and currcci;and that all regulaled activities Will be perforlood in accordance wllh w(I ulg)licubic S,
<br /> JOAQUIN COUNTY Ordinance Codes and/or Standards and S1rATK and/or VUDERAI.Laws and Itcgulatiuns. As the undersigned owner,uperalur,or agent of the propu'ty looted at V
<br /> above facility/site address. 1 hereby authorize the release of any and all rcolu and cnrirontnenlal asstasmcnt information to SAN JOAQUIN C.'OUNrY ENVIkONMENrn
<br /> IIFALTII DIVISION as soon as it is available and at the same time it is provided to me or my rcpraltolalivc,
<br /> PLEASE PRINT
<br /> SIGNATURE
<br /> Ar�PLICANT NAME �r.,so ti �, Go J/l) - '
<br /> TITLE Y I T e c,� I C �P/ DRIVER'S UCENSE� 15 3�3 8 I �T
<br /> �/� /� J fir' �P^� �PHn7fl nPY nFp111RF
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<br /> ..+ tti,' p,�;i�^1"):r!'�^ e ;'v'l'1Y, t.>�:•-Sit:', '.1u._
<br /> �A prtiied ey !,, >•. +J :?Date, �xst , r�.^cWFr`+�rtie' :Aecoun[{ii9'OffioeiPrtaoe�d `Com V e etfg ,
<br /> CONHUMIRLb� ��
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