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San Joaquin County Environmental Health DepartmentE" ` 3 <br /> GREEN FORM <br /> DATE 'f/� MASTER FILE RECORD INFORMATION "MFR" <br /> Fun,rcs no,, oWRERID# CASE# UNIT IV <br /> OWNER FILE <br /> Of£rdrtF OWNER LTMRENrtYONFAEWJTM EXD' <br /> COMPLETE THE FOL LOwrNGPR0PERTY OWNER INFORMATION; <br /> PHONE <br /> PRapatTr OWNER NAME <br /> First MI <br /> Last <br /> BuSiNEss NAME CC, SOcSEc/7axID <br /> 01nI11erHMKAddte55 ` DRIVER'SLToRSE# <br /> 2 52 v ///iii <br /> �Y MA�)�6�< STATE � �j533 � <br /> OWnei Mailing Atdta55 <br /> Mailing Address City State Zip <br /> Tvornrnwncocuro Coppona �( <br /> spry ElINDDDDDAL❑ PARTNERSHID El FED AGENCY ElOIRER 4Q� <br /> FACILITY FILE <br /> FACILITY ID# CROSS REF ID# Accourfr ID# INV# <br /> rnAfPtE7F7NEFaLLQKTNG BUSIN SS I FACILITY I SITE N R TION' <br /> Is this a NEw Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ No <br /> Is this an EXISTING Business LOCATION but a NEW TYPE of regulated Business? Yes ❑ No <br /> BUSINESS/FAt31Tf/SITE NAMEhi cs-Ae r- 1 'Park <br /> SITE ADDRESS R.$"t..SLb t.J -I SURE# BUSME55 PHONE <br /> p 2 o os <br /> CITY C V-At � STAEA g° C1 533 7 <br /> BOARD oFSUPEItVISOR DfsTRICT LOCATION CODE KEYi KEY2 <br /> Mailing Address WD.InTREN71fom Fad1dy ddre Attention:or Care Of(Dvtli a/) <br /> STATE , ZIP <br /> z79 0 qrk)l Ila <br /> Mailing Address City �C ��C C,— <br /> SIC CODE APN# COrdMwr: <br /> THIRD PARTY BILLING INFO; COMPlete d Billing Patty is different from Property Owner or Facility Operator identified above. <br /> BUSINESS NAME \\ Attention:orCare Of tkohlawl) <br /> C <br /> Mailing Address _ pw _ <br /> p S +€ <br /> Cor ZIP 94 QC, a <br /> AwamrAgognar for fees and charges OWNER FACILITY/BUSINESS THIRD PARTY BILLING <br /> Rl1iMsGA1cDC0sAP11ANff APRNOW rncMEN : I,the undersigned Applicant,certify that I am the Ownery oPeraror,or A.rhadzed Age.(of this Business,and!acknowledge that all PERM/I'F£ES, <br /> PENALREa,FNFQECENENFCTIARG£S and/or nGuaLFCNARGES associated with this operation win be billed to me at the address identified above as the 4rc0, rAnnaEsc 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 cover,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 represeomfiva <br /> Pa[ <br /> APPLICANT NAME rfr SIGNATURE <br /> TITLEDRIVER'S LICENSE <br /> Q fPl10T000IW REOUDre # <br /> I <br /> Appmled By Date Arcountng orrice ptswessing Campkbed By Date <br /> 29-02-002 April 25,2003 <br />