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San Jo'c7. Gin County Environmental Health G,oftrtment <br /> GRFEN FORM <br /> DATE S 7-//Aq /J—MASTER FILE RECORD INFORMATION "MFR" <br /> SNenan ARFAC Fng FHn IICF nNi v OWNER ID# CASE# UNIT IV <br /> OWNER FILE <br /> COMPLETE THE FOLLOWING PROPERTY OWNER INFORMATION: CHECKIF OWNER CURRENTLYONFILEwrrH EHD <br /> �gROPERTY OWNER NAMEee- ,O .a PHONE 3 <br /> Q -?—//_ / <br /> First MI Last �Y`fO W sP <br /> BUSINESS NAME /� _ n SOC SEC/TAx ID At <br /> Owner Home Address 1,G 3 Y t�,, DRIVER'S LICENSE# <br /> CitySToL fc�ZD�J i STaTEC� ZZP <br /> Owner Mailing Address <br /> Mailing Address City ` ip <br /> TYVF QF QWNFOSHto <br /> CORPORATION❑ INDIVIDUAL o PARTNERSHIP❑ FED AGENCY❑ OTHER❑ <br /> FACILITY FILE <br /> Fa�ID# CRoss REF ID# Accoulvr ID# INV# <br /> 66tot() R �eu3e�ss <br /> OMPLETE THE FOLLOWING B SINESS I FACILITY I SITE INFORMA710N.' <br /> Is this a NEW Business LOCATION not previously re9uiated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ No <br /> Is this an EXISTING Business LOCATION but a NEW TYPE of regulated Business? YES ❑ No <br /> BUSINESS/FAcnm/SITE NAME <br /> SITE ADDRESS 2v �jll���t V-I�, _/ n SUITE# BUSINESS PHONErVYI b 3� <br /> Cert �C GC t Ln� T7` STATEf� ZIP ej 5720 <br /> BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEYS KEY2 <br /> Mailing Address hrDIFFERENThom Facility Address Attention:or Care Of(optional) <br /> Mailing Address City STATE ZIP <br /> C CODE APN# COMMENT: <br /> THIRD PARTY BILLING INFO: Completed Billing Party is different from Property Owner or Facility Operator identified above. <br /> BUSINESS NAME1 e-� AttAttention:or Care Of (optional) <br /> A <br /> _ �JU�C <br /> [Mailing Address Q 37 -S PHONE /b 7 (h� <br /> CIT' STATE ZIP (� <br /> AMA+WT ADwms for fees and charges OWNER FACILITY/BUSINESS THIRD PARTY BILLING <br /> Rn r rwc AND COMvt IANCF.ACKNnwt.en[:M 'qT: I.the undersigned Applicant,certify that I am the Otw+er.Operator,or Authorized Agent of this Business,and I acknowledge that all PERMIT FEES, <br /> Pen'AL77ES,ENFORCEMENT CHARGES and/or HOURLY CHARGES associated with this operation will be billed tome at the address identified above as the ACCOUNTADDRESS for 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 aB results and environmental assessment information to SAN JOAQUIN COUNTY ENVIRONMENTAL.HEALTH DEPARTMENT as soon as it is available and at the same time itis <br /> provided to me or my representative. <br /> APPLICANT NAME j/j am I PLEASE PtuNT SIGNATURE <br /> TITLE �� /Q / r n .(. DRIVER'S LICENSE# <br /> I (PHOTOCOPY REOUIRED) <br /> Approved By Date Accounting Office Processing Completed By Da--t- <br /> 2 3-02-0 <br /> e29-02-002 April 25,2003 <br />