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San Jodquin County Environmental Health L,,.,artment <br /> GREEN FORM <br /> DATE u-Lw- l�q /4—MASTER FILE RECORD INFORMATION 'MFR" <br /> 5nr ►aF6S FOR FHn ncF nNiv OWNER ID# CASE# UNIT IV <br /> OWNER FILE <br /> CNECK IF OWNER CURRfNTLYON fILf WITH EHD ❑ <br /> COMPLETE THE FOLLOWING PROPERTY OWNER INFORMATION; <br /> PROPERTY OWNER NAME ee-,C -a PHONE <br /> First MI <br /> Last 7 Tr/ f0 r <br /> SOC SEC/TAx ID# <br /> BUSINESS NAME <br /> Owner Home Address DRIVER'S LICENSE# <br /> City STEL K�Z6tJ i STATE/�4 ZIP <br /> Owner Mailing Address <br /> Mailing Address City ip <br /> low— <br /> Ste-. <br /> TYPF nF nwtiFoaarn <br /> CORPORATION❑ INDIVIDUALO PARTNERSHIP❑ FED AGENCY❑ OTHER❑ <br /> a- FACILITY FILE <br /> �ACXIDL CROSS REF ID# ACCOUNT ID# INV# <br /> ooDo�o� R �eu3bgss <br /> OMPLETE THE FOLLOWING BUSINESS EACILITY SITE INFORMATION,' <br /> Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ No <br /> Is this an E)asIiNG Business LOCATION but a NEW TYPE of regulated Business? YES ❑ No <br /> BUSINESS/FACILITY/SrrE NAME <br /> SITE ADDRESS V SUITE .itBUSINESS P�HON2VY �FTVY_I16 3�, <br /> CITY STATE ZIP -i <br /> BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEYS KEY2 <br /> Mailing Address ifDIFFERENrhont Facility Address Attention:or Care Of(optional) <br /> Mailing Address City <br /> STATE ZIP <br /> C CODE [APN# COMMENT: <br /> THIRD PARTY BILLING INFO: Complete if Billing Party is different from Property Owner or Facility Operator identified above. <br /> BUSINESS NAME Attention:ot-Care Of (optional) <br /> F-ma, <br /> ling Address c 7 S d� r�_ - L/ PHONE 2 o 4) r 7 (0b <br /> Cm uQ L� t ' STATE ZIP 1v� <br /> A=LmffAnPR&w for fees and charges OWNER FACILITY/BUSINESS THIRD PARTY BILLING <br /> RTI.t.ING AND COMPLIANCE ACKNDWLEDGM:ENT: L the undersigned Applicant,certify that I am the Omer,Operator,or Authorized Agent of this Business,and I acknowledge that all PERMIT FEES, <br /> PENALTIES,ENFORCEMENT CHARGES and/or f 011RLYCAARGES associated with this operation will be billed to me at the address identified above as the ACCOUNTADDRI_Ce 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,1 hereby authorize the release of <br /> any and all results and environmental assessment information to SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTIINT as soon as it is available and at the same time itis <br /> provided to me or my representative. PLEASE PRINT <br /> APPLICANT NAME � 1)t/�1Grs wv �1 SIGNATURE � 1 <br /> TITLE / �.\ y j. DRIVER'S LICENSE# <br /> (PHOTOCOPY REOUIRED) <br /> Approved By Date '� Accounting Office Processing Completed By (y Date t <br /> 29-02-002 April 25,2003 1-4—<— -? J)I/Z d r-Z' <br />