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San Joaquin County Environmental Health Department <br /> GREEN FORM <br /> DATE 9�o C� MASTER FILE RECORD INFORMATION "MFR" <br /> -;H- ED ARFAS EOR EHn USF ON1 V OWNER ID# �1 � �-� CASE# UNIT IV <br /> d OWNER FILE <br /> CHECK IF OWNER CURRENTLYON FILE WITH EHD ❑ <br /> COMPLETE THE FOLLOWING PROPERTY OWNER INFORMATION; <br /> PROPERTY OWNER NAMEZ-7 �-b <br /> J <br /> First MI Last <br /> BUSINESS NAME ..{!. Soc SEC/TAX ID# <br /> h&k <br /> Owner Home Address '1 n k�(J DRIVER'S LICENSE# (\� <br /> city I Q•C A ST ZIP Z J� <br /> Owner Mailing Address <br /> v'^ SrVTl �1 <br /> Mailing Address City f ! Statr..% Zip 7 <br /> .TV PF fIF 71WNFRGHTP W <br /> CORPORATION❑ INDMDUAL❑ PARTNERSHIP❑ FED AGENCY❑ OTHE <br /> FACILITY FILE <br /> FACILITY ID# J�� CROSS REF ID# ACCOUNT ID# INV# <br /> OMPLETE THE FOLLOWING BUSINESS I FACILITY I SITE NFORMATION- <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/FACILITY/SITE NAME n� �.M,l� /u� ( �AL4 <br /> SITE ADDRESS { �l L Llll� ( SUITE# BUSINESS PHONE <br /> VX L <br /> CITY L C 6 21— STATE ZIP <br /> BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEY1 KEYZ <br /> J Mailing Address ifDIFFERENTt'rom Facility Addressi ®` T�/ tte�n:ore (optional) <br /> t V/� a�tti <br /> fling Address CitySTAT ZIP r Z 3 7 <br /> SIC CODE APN# � COMMENT: <br /> THIRD PARTY BILLING INFO: Complete if Billing Party is different from Property Owner or Facility Operator identified above. <br /> BUSINESS NAME Attention:orCare Of (optional) <br /> Mailing Address PHONE <br /> CITY STATE ZIP <br /> CCOLWI d DRESS for fees and charges OWNER FACILITY/BUSINESS THIRD PARTY BILLING <br /> B11 1 ING AND(COMPLIANCE ACKNOWLRDGMFNT: I,the undersigned Applicant,certify that I am the Owner,Operator,or Authorized Agent of this Business,and I acknowledge that all PERMIT FEES, <br /> PENALTIES,ENFORCEMENT CHARGES and/or HOURLY CI(ARGES associated with this operation will be billed to me at the address identified above as the ACCOr/NTADnRR.yC for this site. I also certify that all <br /> information provided on this application is true and correct;and that all regulated activities will be performed in accordance with aB applicable SAN JoAQUtN 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 itis <br /> provided to me or my representative. <br /> PRlrtr / <br /> APPLICANT NAME f0 Ca kVC 1 LC SIGNATURE Z <br /> TITLE DRIVER'S LICENSE# <br /> (PHOTOCOPYREOUIRED) <br /> r <br />