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1 i 0 <br /> ' San Joaquin County Environmental Health Department <br /> DATE GREEN FORM <br /> MASTER FILE RECORD INFORMATION "MFR" <br /> eFMn r OWNER ID# GIF# UNIT IV <br /> OWNER FILE <br /> ' COMPLETFTNFFOLLOWLNGPROPERTY OWNER INFORMA710N. OLEZWPr OWNER CHNR45Vny0Nf£LFWJDI END <br /> PROPERTYOWNERNAME — ' PHONE /a/ ' /�,� <br /> First MI LLJ Y Last �/�T CJ <br /> LILO <br /> BLKINESa NAME -PoSEC/TAX ID# <br /> OwneTNome Address r SOC <br /> n�/.I VV I,T tp a hl L DREVFR51]�NSE# <br /> lrl <br /> ' OwneT Mailing AtltlR25 �✓h <br /> Mailing Address C"Ity U I(J +O ri <br /> 1. ✓Otv -- (01 <br /> ,wPnanw <br /> [ORPORAnON LY INmYID11AL❑ PARTNER$1®❑ <br /> FEOAGExEY❑ OlttEn❑ <br /> ' FAQurvID# ERO55 REFID# FACILITY FILEAccauxr ID# lxv# <br /> ' COAP—LEM77VIFFOLLOPUNG BUSINESS I FACILM SITE JAUVRNATION.' <br /> LS this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENP YES ❑ _ No 9� <br /> Lsthis an BasaING Business LomrJoN bate NI:wTYPF of regulated Business? YEs Lff No El' <br /> ILLI MIS/FAC6llr/Sire NAME `T <br /> G( <br /> SrIE ADORES /a 1 'A rl S1,1115# N <br /> # BUAESSPPHONE <br /> ' trLr 4on Uv STATE 21P l52{..J3 <br /> BOMeo OTSuvEavlSort DIARIR LounoNCWE BFrl �r2 <br /> ' Mailing Address ifDIFFFRENT#arn Foo/iQA{fdlesR, atlEn14 ar Care Of <br /> �.� , M NI VYLQ <br /> Mailing Address City ( n,/� �Ah "441 1 <br /> ' SIC CooE APIN# - CDMMExI: <br /> THIRD PARTY BILLING INFO; COMPiete if Billing Party is differentfrom Property Owner orFacility,Operator idenbfed above. <br /> eus 1NAMe (` 1 A ntion:urCa OF <br /> I �►L Q �o °once <br /> Mailing Address <br /> C / • r1rJl <br /> llr STATE /1 ZIP `.i.M ✓I V ✓� <br /> 'cr for fees and Charges OWNER FACILDY/BUSINESS 1 <br /> THIRD PARTY BILLING <br /> nn IMG ao rnmr ,eIr Trx : 1,ebe-JInirped Applicant,cenify Iha11 um the Dnneq Oprrvrw,or AmhwiuJAxenr of Ibis Business,and 3 aCMowledge that ail P£aHir F£cs, <br /> PENALTIES,ENMRC£M£NTCTIAW,E and/or HOURLYCHARGES assaaialed with This operadnn will he billnl to me.1 lh,mfi rc.blcn6aed above ns the AfrnnMAMaFPe for this file I abo cerFPo Thal <br /> all Information provided on this aPPlicadon is tnm end..meet;and that all mgulated actiritfaa will be performed in accordance with all aPlAbable Sen JOAQUIN CouHTV Ordinance Codes and/or <br /> Standards And STATE and/or FEDERAL Laws and Regubtioru.As theundersigned owvegoperamr,a,aRcnt of the properly located at the above 6Cfity/gtvaddr s,l hereby aule�rmeibe elcaseof <br /> anv and all results and eneironmonml assessment information to SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPAR i NT as soo as it is vailabM and the ume me it s <br /> p drd to we or my represe/Ry/Hve. I dC.` <br /> APPIICANi'NAME t/�'y L—r���,/_(`""E PRINT <br /> 1 l f 111 111!!! 1'CCC ))) SIGNATURE / <br /> T3TLE <br /> e DRNE <br /> (PHOTORSWPY LICENEWSE# <br /> RIRED) <br /> �A,,omVed By nateA®untlnq O�Pro¢ssinq Completed BY <br /> W2942-002 April 25,2003 <br />