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San Joaquin County Environmental Health Department <br /> (� GREEN FORM <br /> DATE <br /> 7- S'�7 MASTER FILE RECORD INFORMATION "MFR" <br /> Su.nFn A FA%ciao FHn ncc nNi Y OWNER ID# OW()0152111 CASE# UNIT IV <br /> OWNER FILE <br /> COMPLETE THE FOLLOWING PROPERTY OWNER INFORMATION; CNEOCIF OWNER CURRevrzroNFILE wmr EHD ❑ <br /> PROPERTY OWNER NAME J u a n r o, 'a s P— 9 s sa - 9 a s . <br /> First MI <br /> BUSINESS NAME � ;�o E ui m2n� �ale-s LLC SOC SEC rTAxID#�, _Q�3 773- <br /> Owner Horrfe Address -7 IV o e Q. tS T Darvet'S LICENSE# N 4159 o (o 3 a <br /> city FonQ /?a STATE�A Z- 9 A 3 3 <br /> Owner Mailing Address -Za n) e / <br /> Mailing Address Citysee BP a 3 3 <br /> TY TIF rwwrawane ��yy <br /> CORPORATION❑ INDIVIDUAL❑ PARTNERSHIP❑ FwAmocx ElOnm K LL <br /> FACILITY FILE 17 <br /> FACILrrY ID# C,REF ID# ACOOUNT ID# 11 � f <br /> 4n1RSR1- A rtp329 .4 - CD <br /> MP ` tti <br /> J <br /> Is this a NEw Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ No JO r Z <br /> :M <br /> Is this an E)aMNG Business LOCATION but a NEW TYPE of regulated Business? YES ❑ No <br /> BUsD� m <br /> SS�FAITY/SITE NAME Fo r rrr e r RO V Knoll To c c.�i n <br /> I'M.W I'� <br /> SM ADDRESS 3 5 7 0 (=a s Miner "e n u e SUITE# Busum f' <br /> S Te9 D c K To r) STATE /, LP S o S <br /> BOARD OF Supemt90R Otsmcr LOCATION CODE KEYI K-2l I / <br /> Mailing Address rfDIFFERENTfrom Fai i#WAddrrss Owners kI om e �d(J A :O1 Care Of(optional) <br /> Mailing Address City c o li tan a STATE(2 Q ZID <br /> SIC CODE FPN#:: <br /> CO MEKT: <br /> THIRD PARTY BILLING INFO: Completed Billing Party is different from Property Owner or Facility Operator identified above. <br /> Business NAME Attention:orCare Of (opobrnW) <br /> Mailing Address ) ` 9 6 Q d Ck �5 re e- � m-* qoq A ! - / 1 / $ <br /> CITY STATE 9 <br /> dr�nrrur Annvccc for fees and charges OWNER FACILITY/BUSINESS THIRD PARTY BILLING V <br /> BILLING AND f'OMPLIANr ACKNOWLM <br /> EDGENT: I,the undersigned Applicant,certify that 1 am the Owner,Operator,or.lutharited Agent of this Business,and 1 acknowledge that all PERwrr rEES, <br /> PENALTLES,ENF(M(.EMENTCfIARI:ES'apd/or 11()('RL1'CH.4R(:E1;associated with this operation will be billed to me at the address identified above as theAccrx)N2dfor this site I also certify that <br /> 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 <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 D tRTMENT as soon as it is available and at the same time it is <br /> provided to me or my representativePLEASE , <br /> P1+>M <br /> APPSIGNATURE C A <br /> APPLICANT NAME �(lcc 0a ra r&.5 <br /> TITLE DR E ICEN # V /-/ <br /> f � C' D <br /> Approved By Date Aceoe "Office Processirrg Conyleted By fJD9 om <br /> 29-02-002 April 25,2003 <br />