|
-411 -1i .. �
<br /> GREEN FORM
<br /> GATE MASTER FILE RECORD INFORMATION "MFR"
<br /> SnAPEo ARE"FOR EHD USE ONLY $ w,�� I�0
<br /> OGV: /0.5ffb OWNER FILE �Y v
<br /> COAIPLETBTHEFOLLOW/NC PROPERTY OWNER INFORMATION: CHECxiF OWN ERCiURRENTLYONFILE W/THEHD
<br /> PROPERTY �r�CA eL— O PHONE ��77
<br /> U1
<br /> OWNER NAME f 6 l!52--SS
<br /> -S� L�4 L4 t
<br /> rm asr J
<br /> BUSINESS NAME 1, SOC SEC I TAX ID#
<br /> Owner Home AddressDRIVER'S LICENSE#
<br /> 1-21''rc, ��I 111
<br /> City A S 'A STATE ZIP
<br /> Owner MailingAddreaa N
<br /> Mailing Address City t State Zip
<br /> CORPORATION INDIVIDUAL PARTNERSHIP 0 FED AGENCY OTHER
<br /> l 3 1 FACILITY FILE
<br /> _•-,r r:: . I:_n�,�,� ,•nFi _ _ ...;.x:w •rays_. �� �_ .,����Ti :- •„"'•'
<br /> i'•"3;0. , � '4 _i=ii _ ':s,—i =r� r,e•�-sV»•:v�
<br /> urs:.
<br /> COMPLEirETHEFOLLOW/NG BUSINESS I FACILITY I SITE INFORMATION.
<br /> Is this a New Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DlvisloN? YES ❑ No (� I
<br /> Is this an ExlsnNG Business LocATTiioN but a NEw TYPE of regulated Business? YES Q No
<br /> BUSINESWFACILnYISrrENAME
<br /> SITE ADORES$ ” 1^ ` t 'I O ems, i SUITE# BUSINESS PHONE
<br /> CITY
<br /> L+. .._•'�'- S•i..°l•:,rX.:M.1aWu.a$-,•��• ..( ', ti .��,:�..7'I ;"....>=••r�-:--
<br /> n _. mIN.o STATE ?NZ!�I'P
<br /> P»S�1'ti�es:�9::..•• �Sy3
<br /> �.zmG� 6�T7
<br /> .S"..�R_:_ l,ryv � «.. x,•m,�l[:"Jii.i:I44
<br /> r_•.s�s.
<br /> Mailing Address ifDIFFERENTfrom FacffityAddress Attention: or Care Of(options/)
<br /> Mailing Address City STATE ZIP
<br /> err• ••-_. W�., ,., .,:.,W. - _ , .�_.; -_::,;.." - •-�,-;-•,..
<br /> ::'�• INK-12=10- 2.
<br /> i-. ^r._.....: -fir •r 1 .�• �'iEliw` _ jiz:7�ik
<br /> -I I..,:..----�,• y--girl Wa I ,- •..dr...•. _ I _ :.Is,';i�r:�_•�F�4F�-' �•"'- _,4 --,S 4�F�i�',� �a,_:y�_.. : ..,n.�.. -,�i^r
<br /> 1 vis_ :rai5
<br /> -- ..f'i of _ 3... _ :.�'.� :l - �: L :.-•1 - Ma �._ , 1 -:i, :iiS:.
<br /> THIRD PARTY BILLING INFO. Complete fir Billing Party is different from Property Owner or Facility Operator idend>.ed above.
<br /> BUSINESS NAME C y-,C-ii Attention:or Care Of (optional)
<br /> Mailing Address p O Q O X O S -7 PHONE Q.
<br /> Cm S STATE(7 ZIP 9:53
<br /> S
<br /> ACCOUNTAODRE3S for fees and charges OWNER FACILITY/BuslNESS THIRD�/�_PARTYJDILUNG
<br /> BILLING AND CordruANCE ACKNOWLEDGMENT: I,the undersigned Applicant,certify that I.AM the Owner,Operator,or Authorized Agent of this Business,and I acknowledge that all
<br /> PePNJTFF-Es,PEXALT=ENFORCEXENT CHARG£4 and/or HouRLYCHARGES associated with this operation will be billed tome at the address identified above as the ACCOANT ADDAINT
<br /> for this she. I also certify that all information provided on this application is true and correct and that all regulated activities will be performed in accordance with all applicable SAN
<br /> JoAQuiN Couli Ordinance Codes And/or Standards and STATE and/or FEDERAL,IJWs and Regulations. As the undersigned owner,operator,or agent of the property located at the
<br /> above facility/site address, I hereby authorize the release of any and all results and environmental assessment information to SAN JOAQUINE COUNTY ENVIRONMENTAL
<br /> HEALTH DIVISION as soon as It Is available and at the same time It is provided to me or my representative.
<br /> L PRINT
<br /> APPLICANT NAME Yti.IPS rat" �V�f�� SIGNATU G r
<br /> `s
<br /> TITLE DRIVE'R'S LICENSE iE
<br /> !PHOTOCOPY REGUI REDI
<br /> '� � -:._iF..=n �• µPio:='3'" � I ''L;�:i: - '� - _ 3r_ __ _ _ _ _
<br /> ' : •.:: N4c ..is a"a
<br /> V 'd W d WdL�'� 6661-SZ-8l
<br />
|