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e 0 <br /> San Joaquin County Environmental Health Department <br /> y GREEN FORM <br /> DATE ( 0 / MASTER FILE RECORD INFORMATION ` MFR" <br /> OWNER ID# �jCASE# UNIT IV <br /> OWNER FILE <br /> COMPLETE THE FOLLOININGPROPERTY OWNER INFORMATION: CHEC1rIF OWNER CURREN 7z Y ON P"K77H END El <br /> PROPERTY OWNER NAME ' /J f �qs /I� PHONE � 9/4 <br /> First C M/ V 6 Last T V <br /> BUSINESS NAME Soc SEc/TAx ID# <br /> Owner Home Address �a V l lA S I� DKLVER'S���yyyL3CFNSE# <br /> city U v J{ STATE 0 ZIP <br /> Owner Mailing Address +=z- <br /> Owner <br /> I <br /> Mailing Address City iCVn j� O �✓71 state C — ZipC)d/, <br /> TYPF nF O] Fncwrp J LJF� v <br /> CORPORATION INDIVIDUAL© PARTNERSHIP❑ FED AGENCY❑ OMER❑ <br /> FACILITY FILE <br /> FAcmm ID# ryCRoss REF ID# Accouwr ID# INV# <br /> OMPA TNEFOV LLOLVINGFACILITY I SITE rNFORMAITON! <br /> Is this a NEW Business LOCATroN not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YEs El No 0-- <br /> Is this an E)asTING Business LOCATION but a NEW TYPE of regulated Business? YES No l]� <br /> BusINESs/FAcuxrY/SITE NAME <br /> SITE ADDRESS � SUITE# BUSINESS PHONE <br /> L�/•I� r j/l f <br /> CITY - STATE ZIP 9152-63 <br /> BOARD OF SuvERvtsoit DISTRICT LOCATION CODE KEY1 KEY2 <br /> Mailing Address ifDIFFERENTfrom FML L A ntion:'or Care Of V. iv) �1 <br /> J STATE ZIP /f� IBJ ^ 1�q <br /> Mailing Address City ` � � C�� 7 <br /> KC.-E `APN# r✓v COMMENT: B J <br /> THIRD PARTY BILLING INFO: Complete if Billing Party isditferentfrom Property Owner or Facility Operator idenG'fred above. <br /> BUSINEss NAME ,n A nt!on:orCa ,Of Orta/) <br /> fC f� <br /> 1—m-IffP"ON ng Address E [�fI 110 <br /> cl7rL, STATE /r lP y (R S3 <br /> 9crr4oper. for fees and charges OVMER FACILITY/BUSINESS THIRD PARTY BILLING <br /> Ru l lac A�'D CQMPUA,N'CF.ArKN?jXL LDf,MFNT: ],the undersigned Applicant,certiry that 1 am the Owner,Ojxrufur,or Authorized�tgent of this Business,and I actmowledge that all PERAHT FEES, <br /> PFNAf.77ES,F,h'FORCEMEh-t CHARCF_S amllor 1lOf/R1.Y CHARGF_S aSSa[iatet$with this operation will he hilled to me at the address identified above as the ACCOUNT,101) '.SS for this site. 1 also certifi-that <br /> all information provided an this application is true and correct;and that all regulated activities will he performed in accordance with all applicable SAN JOAQUIN COUNTY Ordinance Codes andlor <br /> Standards and STATE andlor FEDERAL Law's and Regulations. As the undersigned owner,Operator,or agent of the property located at the above facility/'te addr ,1 herby aUt rize tie• ien_se of <br /> anv and all results and environmental assessment information to SAN JOAQUTN COUNTY ENVIRONMENTAL HEALTH DEPART NT ns soo as it is vailable and the same me it is <br /> provided to me Or my repress/u�tJ�tive. t_'Jh <br /> APPLICANT NAME 1h`!1 �T) , n, ..1 EASE PRrnT SIGNATURE <br /> 1 ) [�[,(11 CCC JJJ 1 <br /> TITLE DRIVER'S LICENSE# <br /> '7 (PHOTOCOPY REOUIRED) <br /> Approved By a Date I > (7 Accounting O ftce Processing Completed By AJT I Date <br /> 29-02-002 April 25,2003 <br />