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Cav-4c, 'Tie.a CO ail
<br />BUSINESS NAME
<br />STATE CA ZIP q 15
<br />CITY 4.0 a.C, VA.
<br />TITLE D-6clii-oc- DRIVER'S LICENSE #
<br />(PHOTOCOPY REQUIRED) -
<br />Date Approved By Accounting Office Processing Completed By Date
<br />29-02 10/12107 MASYFR FILE RECORD-GREEN
<br />Attention: orCare Of (optional) ,
<br />c--keAr
<br />pHoNE00 e32.1 Li 3 5 v'°4 -e- 2'55
<br />Mailing Address 655 un; veir5i 4.7
<br />BILLING AND COMPLIANCE ACKNOWLEDGMENT: L the undersigned Applicant, certify that lam the Owner, Operator, or ,4uthorized Agent of this Business, and I acknowledge that all PERMIT FEES,
<br />PENALTIES, ENFORCEMENT CHARGES and/or HOURLY CHARGES associated with this operation will be billed to me at the address identified above as the ACCOUNT ADDRESS for this site. I also certify that
<br />all information provided on this application is true and correct; and that an 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 repr sentative.
<br />APPLICANT NAME PLEASE PRINT Ri\ci. Bv.„ SIGNATURE
<br />ALVOUNTADDRESS for fees and charges
<br />OWNER
<br />
<br />FACILITY/BUSINESS
<br />
<br />THIRD PARTY BILLING
<br />DATE
<br />San Joaquin County Environmental Heaito Department
<br />MASTER FILE RECORD INFORMATION "MFR" Cl 2-Cc GREEN FORM
<br />OWNER ID# SHADED AREAS FOR EHD USE ONLY UNIT IV CASE #
<br />OWNER FILE
<br />COMPLETE THE FOLLOWING PROPERTY OWNER INFORMATION: CHECK IF OWNER CURRENTL r ON FILE WITH EHO
<br />tiaRnozaualutiE,R-NANTE-" PHONE
<br />First MI Last
<br />43ENCE;aiete-C LA) nex. r- ..,,, --- t - b-F 54-b
<br />(.. jc.47,, SOC SEC /Tax ID # cclevtAcipryle,cd-
<br />‘..."
<br />Owner Home Address
<br />Al 4
<br />DRIVER'S LICENSE #
<br />City
<br />(e---- STATE 0 ZIP
<br />Owner Mailing Address
<br />14 25 Al • Z )' 4,0t-t0e)
<br />Mailing Address City
<br />$4V Ck-I''-7-le -
<br />State Zip *7...le 2.....,
<br />TYRF OF OwNFRRHIP
<br />CORPORATION 0
<br />
<br />INDIVIDUAL 0
<br />
<br />PARTNERSHIP 0
<br />
<br />FED AGENCY
<br />OTHER 0
<br />FACILITY FILE
<br />FACILITY ID # CROSS REF ID # ACCOUNT ID # INv#
<br />COMPLETE THE FOLLOWING BUSINESS / FAC I LITY / SITE INFORMATION:
<br />Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPT? YES N. NO 0
<br />Is this an EXISTING Business LOCATION but a NEW TYPE of reaulatArl Ri 'Ain...? YES E] No ISI,
<br />l 54-1, C-r-Prel lee cie-0 efere irria:Tv+ki.....7-%-e (J.__
<br />BUSINESS/FACILITY/SITE NAME 5 Az. I -..... Hy .„1--_,„„.' 4),,„.. e_ - s , iv . 2_ :: I/ e.,...c,,,,,k" 1144, ;,1 It* At.{A.,,,,,,LC _,,,, 4-1- a o 494,'-'7 )
<br />SITE ADDRESS ,FiatIR O E.i,jtbe-r / 3 oo (4). b144-- t_e_-/- SUITE # Ithl BUSINESS PHONE hill
<br />CITY
<br />5.4tc-- '17,".
<br />STATE 61 ZIP
<br />BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEY1 KEY2
<br />Mailing Address if DIFFEREAIT from Facility Address Attention: or Care Of (optional)
<br />Mailing Address City STATE ZIP
<br />SIC CODE APN# COMMENT:
<br />THIRD PARTY BILLING INFO Complete //Billing Party is different from Property Owner orFacility Operator identified above.
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