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San Joaquin County Environmental Health Department <br /> GREEN FORM <br /> DATE MASTER FILE RECORD INFORMATION "'MFR" <br /> CuenFn eRFec Frig FMn IICF Om V OWNER ID# !'t J\ T:) CASE# UNIT IV <br /> OWNER FILE <br /> COMP=THE FOLLOWING PROPERTY OWNER INFORMA770N; CHECKIF OWNER CuaRENrtroHFrLEwrTH EHD <br /> PROPERTY OWNER NAME -7v—,5o Al ,p PHONE <br /> Fir1 16 st✓ / MI C Last <br /> /1 ` J O <br /> BUSINESS NAME 0 t ,-/ l_{-W��5 � SOC SEC/TAx ID# <br /> Owner Home Address 3 '7 5-0d � &10oG(/6r1 e ew, DRIVER'S LICENSE#' <br /> r <br /> City n�l STATE uP <br /> Owner Mailing Address <br /> Mailing Address City /,/ba n /1//IW 7 ! State Zip ?'5ws—$ <br /> TVDF nF nwNFRCMTR <br /> CORPORATIONINDIVIDUAL❑ PARTNERSHIP❑ FED AGENCY❑ 11OTHER <br /> I, FACILITY FILE <br /> FACILITY ID# `-f'� CROSS REF ID# ACCOUNT ID# 3 INV# <br /> COMPIE7FTHEFOLLOWING <br /> ll A77 N' <br /> Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ No <br /> Is this an E)aSTING Business LOCATION but a NEW TYPE of regulated Business? YES ❑ No <br /> BUSINESS/FACILITY/SITE NAME <br /> SITE ADDRESS SUITE# BUSINESS PHONE 6$ :33 <br /> JJ 7 <br /> CITY STATE <br /> ,',4 z1P <br /> BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEY1 KEY2 J <br /> Mailing Address ifDIFFERENTfrom FacilityAddness Attention:or Care Of(ogtiana/) <br /> Mailing Addre/ss City /,J�D D/I Q j STATE""A Z.P 5-"2 s <br /> l�/t <br /> \I J $IC CODE APN# COMMENT: <br /> THIRD PARTY BILLING INFO: Comp/ete if Billing Party is different from Property Owner or Facility Operator identified above. <br /> BUSINESS NAME Attention:or-Care Of (optional) <br /> Mailing Address PHONE <br /> CITY STATE zip <br /> e rrnrnvr ennnccc for fees and charges OWNER FACILITY/BUSINESS THIRD PARTY BILLING <br /> Bn.t.irva Arvn C'OMPLIANCF ACKrvowr.encMFNT: 1,the undersigned Applicant,certify that I am the Owner, Peru aq or Authorized Agent of this Business,and I acknowledge that all PERMIT Fees, <br /> PENAL.T/E.S,ENFORCEMENT C'NARGES and/or HOURLYCILARGES associated with this operation will be billed to me at the address identified above as the ACCOUNT ADDRR,CQ for this site. I also certify that <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 Ordinance 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 facility/site address,I hereby authorize the release of <br /> any and all results and environmental assessment information to SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my representative. <br /> r' <br /> APPLICANT NAME ! (f �/�p(7 PLEASE PRINT <br /> � SIGNATURE <br /> TITLEDRIVER'S'p DRIVER'S LICENSE# _ <br /> Vi L t. /0/- -J ��C �/�� (PHOTOCOPY REOUIRED) ' <br /> Approved By �(,L Dater2" Accounting Office Processing Completed By Date b <br /> 29-02-002 April 25,2003 <br />