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San Joaquin County Environmental Health Department DATE 1 MASTER FILE RECORD INFORMATION "MFR" GREEN FORM �/Of CNSnFn ePFeC Frig FHn imp nin y OWNER ID# -7 CASE# UNIT IV /// OWNER FILE COMPLETETHEFOLLOWINGPROPERTY OWNER INFORMATION; CHECKIF OWNElR/l CUI RREN1 rzlYOON-FILE wrnEH D PROPERTY OWNER NAME Kc PHONE C)-n3 First Ml Last ❑ BUSINESS NAME sk OGV�on SOC SEC/TAX ID# Owner Home Address / � /',/Ih I� !� / 1Y / DRIVER'S LICENSE# Cloy r� SATE / ZIP a C J , Owner Mailing Address `7 ( CJ 1. �� L1✓�, -Y`-fit/ Mailing Address City / / State /� zip `/C Oc o✓�. C� J t TYPF nF AWNFR mTP '�{ CORPORATION❑ INDIVIDUAL El PARTNERSHIP❑ FED AGENCt� OTHER❑ FACILITY FILE FACILITY ID# ' D CROSS REF ID# ACCOUNT ID# oZ 9 3-,-7 INV# COMPLETEM Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ No x Is this an EXISTING Business LOCATION but a NEW TYPE Of regulated Business? YES ❑ No BUSINESS/FACILITY/SITE NAME S��>G� �C�� c,��%r d I S 6-'C-' ,^ SITE ADDRESS _ Ea��lI,II4 NG,� 5�e SUITE# BUSINESS PHONE r CITY STATE ZIP BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEYS T KEY2 Mailing Address ifDIFFERENTfrom FadlityAlddriess Attention:or Care Of(optional) Mailing Address City STATE ZIP E ECO- APN# Comm THIRD PARTY BILLING INFO: Complete if Billing Party is different from Property Owner or Facility Operator identified above. BUSINESS NAME Attention:orCare Of (optional) MWO evo-,r' 50,Ph Mailing Address *332-1 '�o wor -3vo PHONE 9)(vq) a — �i q 1j Cil'1I $ac rL`l vwe lo 'ro STATE C�� ZIP errvvavr Ari—for fees and charges OWNER FACILITY/BUSINESS lTHIRD PARTY BIL1LING Rn i.iNe nNn f'OM PI JANCF.ACKNowi.Fi)GmEN�r: ],the undersigned Applicant,certify that I am the Owner,Operator,or Authorked Agent of this Business,and ac owe ge that all PERMIT FEES, PEM4LTIFS,ENFORCEMENT CIIARGES and/or HOURLYCHARGES associated with this operation wW be billed tome at the address identified above as the ArroUNTADDRF]CC for this site. I 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 JOAQUIN COUNTY Ordinance Codes and/or 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,1 hereby authorize the release of any and all results and environmental assessment information to SAN JOAQUIN COUNTY ENVIRONNIENTAL HEALTH DEPARTNIT moon#is it is available and at the a time it is provided to me or my representative. APPLICANT NAME �� PLEASE PRINT SIGNATURE TITLE ��fa �J 'S *� DRIVER'S LICENSE# (PHOTOCOPY REOUIRED) Approved By Date W Accounting Office Processing Completed By Date121 C75- 29-02-002 April 25,2003