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San JcyAGin County Environmental Health Ddlektment <br /> DATE $ GREEN FORM MASTER FILE RECORD INFORMATION "MFR" <br /> SHA OWNER ID# :=: —]—TSE# UNIT f V <br /> OWNER FILE <br /> COMPLFTETHEFOLLOWING PROPERTY OWNER INFORMA 710N; CHEcKIF OWNER CURRENTLYONFZLEWITH EHD <br /> PROPERTY OWNER NAME rcA <br /> PHONE — <br /> First M1 Last V <br /> BusmEss NAME --JT Soc SEc/TAx ID# <br /> Owner Home Address q ` 6o I DRIVER'S LICENSE# <br /> r <br /> city <br /> SPATEG4 I ZIP <br /> Owner Mailing Address p <br /> Mailing Address City State Zip <br /> Nth Q U e <br /> Cf <br /> Z'✓PF Ae nWNFASNTfJ <br /> CORPORATION❑ INDWIDUAL❑ PARTNERSHIP❑ FED AGENCY❑ <br /> OTHER❑ <br /> FACILITY FILE <br /> FACILm ID At CROSS REF ID# J— ACCOUNT ID# INV# <br /> OMP ETE THEFaugwriva a SINESS I EACILITY I SITE LMEORMA770N.' <br /> Is tills a NEW Business LOCATION not previousiv regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ No ❑ <br /> Is this an DaSTING Business LOCATION but a NEW TYPE of regulated Business? YES ❑ No ❑ <br /> BUSINESS/FACILITY/SrtE NAME 11aG a r1Sn('] <br /> SM ADDRESS 2 /OV��+ SUITE# BUSINESS PHONE <br /> CITY N> STATE Cft Zip <br /> BOARD OF SUPERVL9DR DISTRICT LOCATION CODE KEY1 KEY <br /> Mailing Address LfDYFFEREA7hntn FadlityAddress Attention:or Care Of(optional) <br /> Mailing Address City STATE Zip <br /> JKC.O.E APN# COMMENT: <br /> THIRD PARTY BILLING INFO: Complete if Billing Party is different from Property Owner or Facility Operator idenfffied above. <br /> BUSINESS NAME 4CA111A 1.5eo <br /> r�� I Attention:or Care Of (optional) <br /> Mailing Address J� i ) i PHONE f00 �f/_ `SCO <br /> Ww . oCJv I In J^�J <br /> �, STATE ZIP TSP'1 C— <br /> .GCOlIAq-"DRm;F for fees and charges OWNER FACILITYIBUSINESS THIRD PARTY BILLING <br /> 1,the undersigned Applicant,certify that I am the Owner,Operator,or Authorized Agent of this Business,and I aclmowledge that all PBRWr FEES, <br /> PlxtLTTEs,ENFORCFht1 N!Cff 1RGFs and/or HVURLrCXARGF-5 associated with this operation will be billed tome at the address identified above as theAccouxrRDnxFSS for this site I also certify that <br /> all information pro1ided on this application is true and correct;and that all regulated activities will be performed in accordance with all applicable SAH JOAQUW COUNTY Ordinance Codes and/or <br /> Standards and STATE andlor FEDERAL Laws and Regulations. As the undersigned owner,operator,or agent of the property located at the shove facilitylsite address,I hereby authorize the release of <br /> any and all results and environmental assessment information to SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT assoon as It is available and at the same time it is <br /> provided to me or my representative. <br /> PL E PRINT ATURE <br /> SIGN <br /> APPLICANT NAME r(pIh i MGY1 <br /> TITLE DRIVERS LICENSE# <br /> (PHOTOCOPY REOLIRED) <br /> Approved By Date Accounting Office Pnxwsing Completed BY Date <br /> 29-02-002 April 25,2003 <br />