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San Joa GREENFORM <br /> uin County Environmental Health De artment <br /> 09 <br /> DATE MA R FILE RECORD INFORMATION "A <br /> SNapa,AgE aFog EHO u6E ONLY OWNER IDN CASE* UNIT IV <br /> OWNER FILE <br /> CommErEYwFottowNePROPERTYOWNER IhFor<emwN.• CfwOWNERClanno troy ENmfEND <br /> PacipanvOWNERNAME3 4 PHONE gz ? '���„ <br /> Rrst i MI/// Last ```��/ <br /> BusiNEs;NAME /X LG G Soc SEclTAZID* 641-6 L o7a <br /> Owner Home ss <br /> Addre' lI DRNTR'SI.ICENSEN /// I <br /> city �9 �/1/ ,/ / STATE zip <br /> owner Mailing Address /l3 Z v r/r 0-4<- r vt Ct-L jc- Cj A 255 J <br /> Mailing Address City ,�� ,nabs Zip <br /> COgPORMN❑ INOMDIIAL❑ PMINERsHW,Ly_ F®Aa®Icr❑ •{,',o r <br /> FACILITY/FILE uu 99 <br /> FACILITY ID N CROSS REF ID If ACCOUNT ID N INV* <br /> Commit B rHEFoLLowtNe BUSINESS/FACILITY I SITE/NFORmATJON.• <br /> Is this a NEW Business t.00AT1ON not previously regulated by the ENVIRONMENTAL HEALTH DEPT.? YES ❑ NO <br /> Is this an EXISTING Business LOCATION but a NEW TYPE of regulated Business? YEs ❑ No <br /> BUsaNESWAGIRYISm NaME - M <br /> tint Appgisg TEN BUSINESS PHONE <br /> Cm STATE LP <br /> r <br /> BOARDOFSUPERVISOR DISTRICT LOCATION CODE KErl KEY2 <br /> Meiling Address HD/FFERENrlrDfn FaaWAd hers Attention:w Care Of topuwe/1 <br /> Melling Address City STATE LP <br /> SIC CODE APNIt COMMENT: <br /> TNnus PARTY BILLINo INF*,. Complete ifBilling Party is different from Property Owner or-Facility,Operator identified above. <br /> BUSINESS NAME Attention:co-Care Of ioDdonaQ <br /> Mailing Address PHONE <br /> cm STATE ZIP <br /> AIXdOfldtTAOaHESB for fees and Charges OWNER FACILITY/BUSINESS THIRD PARTY BILLING <br /> BILLING AND COMPLIANCE ACKNOVR.EDGMENT: L the undersigned.Applicant,certify that 1 am the Owner,Operator,or Authod,ed Agent of this Business,and I acknowledge that all PE 17 FEES, <br /> PENAf.nq ENfaiRCEM Cl' ,'' a and/or HOM.YCfr &%associated with this operation will be billed W me at the address identified above as the AcCnr/ATADDnoEss for this site. 1 also certify I]IM <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 Ordimnre 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 facifity/site addresa release of <br /> hereby authorize the releaof <br /> any and all results and environmental assessment information W SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it e available and at the same time it b <br /> provided to me or my representative. <br /> APPLICANTNAME PLEASE PRINT SIGNATURE . <br /> 1,'_^I. DRIVER'S LICENSE* <br /> ME ���{/ / (PrrnT000py REQUIRED) <br />