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San quin County Environmental Healt' -apartment <br /> GREEN FORM <br /> DATE MASTER FILE RECORD INFORMATION "MFR" <br /> cwsn o e FHn„v nw,. OWNER ID# ( /< 1Z .CASE At UNIT I Y <br /> OWNER FILE <br /> COMPLETE THE FOLLOWING PROPERTY OWNER INFORMATION; CHEcKrF OWNER CURRENTLY ON FILE WITHEHD <br /> PROPERTY OWNER1) O 0. 1 PHONE If 7 <br /> NAME C11 <br /> First MI last <br /> BUSINESS NAME , SOC SEC/TAX ID# <br /> r�3 DRIVERS LICENSE# !� <br /> City STATE <br /> C" <br /> Sz 1 I <br /> Owner Mailing Address <br /> Mailing Address City � ��� J C� State/ 1S— Zip S <br /> TYPF nF nWNFgccHTp <br /> F-1 T.—.... 11 r�� I^ l.A <br /> r nptX1D 1T1TnN ��1OTTIFOCI-11D I ' FFn�r:FNfY 11 rTTLJFp I I <br /> FACILITY ID# ,.b '✓ l CROSS REF ID#. ".. ACCOUNT ID#. ,. C�-.(J�.-� _ - Irry#. <br /> Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ No ❑ <br /> Is this an EXISTING Business LOCATION but a NEW TYPE of regulated Business 7 YES ❑ No ❑ <br /> BUSINESSi FACILITY/SITE NAME <br /> ftt E <br /> SITE ADDRESS SUITE At BUSINESS PHONE <br /> L542 <br /> CITY _ STATE <br /> uP <br /> IIBOARD OF SUPERVISOR DISTRICT ( I LOCATION CODE I I KEYl I I Ktv2 I II <br /> Mailing Address ifDIFFERENTfrom FaciGtyAddress Attention:or Care Of(optional) <br /> Mailing Address City STATE ZIP <br /> SIC CODE APN# COMMExr; <br /> THIRD PARTY BILLING INFO: Complete if Billing Party is different from Property Owner or Facility Operator identified above. <br /> BUSINESS NAME Attention:or Care Of (optional) <br /> Mailing Address l0 2 f 5 1 s ,' PHONE 2,07 <br /> 7 �/ —7 7 7 <br /> l (J �/V O ( b [ I <br /> CITY L. o n STATE C q— ZIP Q C Z_([ <br /> rCOLLnr-ADDREcc for fees and charges OWNER FACILITY/BUSINESS THIRD PARTY RILLING <br /> Bn.1_iNG AND C ONIPI.IANCE.Arhnny{'I.EDCMENT: 1,the undersigned Applicant,certify that 1 am the Owner,Operator,or Authorized Agent of this Business,and I acknowledge that all PERAtLT FF.F.S, <br /> PE,vALnes,EvFoRCEnt&vTCHARGES and/or lroVRLYCLIARGES associated with this operation will be billed to me at the address identified above as the ArrrU/NTAnnRF.CS for this site. 1 also certify that all <br /> 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 ab ve facility/site address,1 herebv authorize the release of <br /> any and all results and Ion mal arse rmation to SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH ARTM T as soon 1 vailable and at the same time it is <br /> provided to me or my epr entat 'e. <br /> PLEASE PRINT <br /> APPLICANT NAME R r(�/ SIGNATURE <br /> TITLE �®!�f 1 7 h�t N� DRIVER'S LICENSE#(PJ <br /> HOTOCOPY REQUIRED) <br /> r <br /> Approved By Date Accounting Office Processing Completed By Date <br /> eo <br />