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B-25-1999 11 :09AM FROM P 2 <br /> GREEN FORM <br /> DATE MASTER FILE RECORD INFORMATION ttMFR'fVObQ'fy <br /> %MADE n AREAS FOR END UBE ONLY UNIT IV ./ <br /> OWNER FILE <br /> COMPLETE THE FOLLOWING PROPERTY OWNER INFORMATION: CNECr7F OWNER 0URRENMYOA,914,5WTHEHD <br /> PROPERTY (�1 J , )In� � PHONE <br /> OWNER NAME n yP . G IS v-ou SCS Oq 7�) `117 <br /> GYH/ n MI ^cif <br /> BUSINESS NAPE I t. �C tt� 1 rl/ _ /v ( � 71, <br /> 1 SOC SEC I TAX ID O <br /> Owner Home Address !,/Il. ,yI�J l I I DRtVER'S LICENSE Y <br /> city S� STATES zIP 5 wz- r <br /> owner Mailing Addrma L <br /> Mailing Address City J State Zip <br /> CORPORATION INDIVIOUAL PARTNERSHIP 71 FED AGENCY ElOTHER <br /> O/ ISFACILITY FILE q <br /> _COMPLETETHEFOLLOW/NG BUSINESS / FACILITY I SITE INFORMATION: �q <br /> Is this a New Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DIVISION? YES Ip1 NO ❑ <br /> Is this an ExIsTINO Business LOcATION but a N11%,TYPEof regulated Business 7 YES ❑ No <br /> BUSINess/FACILITYISITE NAME 6 CLA 1 I �1 e I / <br /> YI'IVn1 IVn\�✓V Y�IA <br /> SITE AOORESs I- �l �/ $UITE2 BUsmIgS PHONE \ <br /> 'p'�fx Iou6J5(n111AAAey,Ata . 6,4wesmVCtidlyem5+ EI4N (.wJ P(6vv AAS`t (SuIR)V,tk—ff-1MAOl <br /> CITY C / /n STATE UP <br /> J°'WtS/•.'('�i/i{�TIT�1'C ii nr'QM v'�ryv R�dMr4/1� YSi,�{N..J <br /> ��66 ICey I��fsr r <br /> Mailing Address it'DIFFERENTfratn Facility Address Attention: or Care Of(optlonal) <br /> 5'Ee l7WW.li dc%ErPS� <br /> Mailing Address City STATE ZIP <br /> t}hr ,n WAI t^r .,C I,h'°:P: y ,� t I I , t, <br /> $1C COt>E. , a,:Ate ' Th4PMfY.1_JI:' �OMMETIT,p.. „t d i. 4!,r ( sI r, <br /> THIRD PARTY BILLING INFO-. Complete if Billing Party isdiRerent from Property Owner or Facility Operator identified above. <br /> BUSINESS NAME Attention: or Care Of (optlonaq <br /> Mailing Address PHONE <br /> CITY STATE ZIP <br /> AecouNT,.IooREss for fees and charges OWNER FACILITY/BUSINESS THIRD PARTY BILLING <br /> BIU,ING AND CUMPLIANCE ACKNOWLEDGMENT; L the a.. migned Appiimat,certify that 1 am the One,,Opermnr,or AuthoderdAgmt of this Basins,and 1 acknowledge that all <br /> MWa FLU.PSNAI.TtEe,ENPORCGMENTCH"r9i and/or FfoCRLr CNRaTs aaweiated with this opmttion will be billed to me at the address ideetirted above as the AgVVNTADDRSy <br /> for this site. I also mrtify,that all information provided on this applintion is true and correct;and that all regulated activitio wfll be performed in accordance with all applicable S,Vi <br /> JOAQUIN CODNTY Ordinance Codes mWor Standards and ST.*,M and/or Fs aaAL Laws and Regulation As the undersigned owner,operator,or agent of the property lotated at the <br /> ahove facility/site address, I hereby audwrFe the release of any and all mutts and eavitonmental aaccment information M SAN JOAQVIN COUNTY ENVIRONMENTAL <br /> HEALTH DIVISION as soon as it is availabk and at the same time it is provided to are or my representative. <br /> PLEASE PRINT � <br /> APPLICANT NAME �r�i'14� SIGNATURE <br /> TITLE Fri on joed An J � DRIVER'S LICENSE <br /> -�4� /PHOTOCO�P9TrRTP�OIrIRFlrI <br /> Apprm•,ed.8� aa11 ~; lfOa «.SM . i>(-::, .1, 4Aeeoun e "'^ ess� Co pKt9oAaY'5"�Q;h. nrtr.r aF r. i t�B;F wr '..r, <br />