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San J( An County Environmental Healtl apartment <br /> GREEN FORM <br /> DATE MASTER FILE RECORD INFORMATION "MFR" 1C F <br /> LIV <br /> OW ' 1 "NER ID# - CASE# ? _ I OWNER FILE �J <br /> COMPLETE THE FOLLOWING PROPERTY OWNER INFORMATION; CHECKIF OWNER CURRENTLYONFfLEwiTHEHD <br /> PROPERTY OWNER PHONE <br /> NAME 2 <br /> � O' 0. CA -10 <br /> Firs( MI las( V l •lJ <br /> BUSINESS NAME SOC SEC/TAx ID# <br /> -�� 3�Z"O DRIVER'S LICENSE# Gj <br /> City v v G/` l� V STATE ZIP <br /> Owner Mailing Address 36 <br /> 18 <br /> L <br /> Mailing Address City �-tr,r� State Zip <� c <br /> TYPF nF nwNFIR-HTP <br /> rnORADSTinN I I TNn Mnllel 1 I DAOTNcocuro 11 Ccn ArFN('V 1 1 rv,v,cR I I <br /> FACILITY ID# CROSS REP ID# AccouNr ID# - Irrv# _ <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 /> BusINEss/FACILITY/$ITE NAME <br /> SITE ADDRESS SUITE# BUSINESS PHONE <br /> CITY STATE ZIP <br /> BOARD OF SUPERVISOR DISTRICT LocnTIoN CODE, KEY1 .. .- .I KEY2,•,,�.,..I II <br /> Mailing Address ifOIFFERENT/Som Facility Address Attention:or Care Of(optional) <br /> Mailing Address City STATE ZIP <br /> ASIC CODE^ APN# COMMErrt <br /> -THIRD PARTY BILLING INFO: Complete if Billing Party is differentfrom Property Owner or Facility Operator identified above. <br /> BUSINESS NAME YY 11 Attention:or Care Of (optional) <br /> 0. <br /> Mailing Address b 2 n'I S 1 n / PHONE 2-o7 <br /> 767 3 7 C <br /> CITY V D I STATE C< ZIP <br /> A:CCOI/ITALU CFCQ for fees and charges OWNER FACILITY/BUSINESS THIRD PARTY BILLING <br /> R11.1.1NG ANn COMPI.IAN(T.AchNo%%i.EDGMENT: 1,the undersigned Applicant,certify that 1 am the Owner,Operator,or Authorized Agent of this Business,and I acknowledge that all PERAOT FEES, <br /> PENALTIES,ENFORCEMENT CHARGES and/or 11OURLYCHARGES associated with this operation will he billed to me at the address identified above as the ACCOUNTADDRES 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 properly located at the ab ve facility/sile address,I hereby authorirc the release of <br /> any and all results and 1 on ntaI arse rmation to SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH D . ARTM T as soon 1 . vailable and at the same time it is <br /> provided to me or my epr on <br /> tat 'e. <br /> PLEASE PRINT <br /> APPLICANT NAME Q I / SIGNATURE <br /> IC\IIAL <br /> ,,ELIL 4--0 <br /> TITLE <br /> �, p� J 1� s Nc DRIVER'S LICENSE At <br /> ! (PHOTOCOPY REOUIRED) <br /> Approved BY Date Acco inting Office Processing Completed BY Date !6 <br />