Laserfiche WebLink
0 • <br />San Joaquin County Environmental Health Department <br />MASTER FILE RECORD INFORMATION "MFR" <br />f;RFFN FORM <br />OWNER FILE <br />....•.. r.•" L.,........ -•w. , CHECKIF OWNER CURRENrLYONFAEnwH EHD n <br />(iOMYLY/E /Mt wt.�ury/nv <br />rrtvr�rs" s ve. r. �.. <br />••••—•••••�•••—•-• <br />DiTYLIVERMORE <br />G <br />OF SUPERVISORDISTRI4T QJ <br />p <br />LOCATION CODE Q 1 <br />Kul <br />Ki <br />PHONE 926580-0777 <br />PROPERWOYMERNMIE <br />timid <br />C larynan <br />SIC CODE <br />APN# 10-6go _ i 4 <br />First <br />MI Lest <br />TAX ID # <br />BUSINESENAME Shea Mountain House LLC <br />Owner HomeAddress5l Belle Avenue <br />DRIVER'S LJCENSE9 <br />STATE CA <br />I L,94960 <br />City San Anse mo <br />Owner Malilag Addrosa 2630 SHEA CENTER DRIVE <br />Meiling Address City LIVERMORE <br />6mm CA <br />ZIP 94$$1 <br />CORPOMTION❑ INDNIDUAL❑ <br />PARTNERSHIP ❑ <br />FED AGENCY❑ LLDE <br />FACILITYFN.E _bkiuuq emb <br />FACILITYID# ��;w GRosa REF ID TK',2AOO� Ac oUNTI NO INV# <br />IT <br />Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH YES ❑ No ❑ <br />IS this an EXISTING Business LOCATION but a NEW TYPE of regulated Business? YES ❑ No ❑ <br />...._...___..._.._.��.�u..._.-.._. .. _...._.... I.,.. ....I l r• 1-111 1.1 A.I.f v; /1, <br />SUITE# BUSINESS PHONE 925,246-3600 <br />SITEADDRESS 2630 SHEA CENTER DRIVE^ U/1 <br />STATE CA 7jP94551 q6:�) j/ <br />DiTYLIVERMORE <br />G <br />OF SUPERVISORDISTRI4T QJ <br />p <br />LOCATION CODE Q 1 <br />Kul <br />Ki <br />KEY2 <br />Mall Ing Address IfDIFFERENrrioln Facility Addlasa Attention: ar Care Of(opdonal) DAVE SARGENT <br />Mailing Address City STATE LP <br />SIC CODE <br />APN# 10-6go _ i 4 <br />COMMENT: <br />THIRD PARTv BILLING INFO,' COmpletelt Billing Parry ISolrierenrrf-olnl-Tupel Ly wwuor yr . o-. j ..H ..--•-• <br />BUSINESS NAME <br />Meiling Address <br />CITY <br />Attention: orCam Of (optional) <br />STATE LP <br />ACCf VIYEA ORESi for fees and charges OWNER FACILITY1BuslNESS THIRD PARTY BILLING ' <br />BILLING AND COMPLUINM ACRNOWLEDCMENT: 1, the undersigned Applicanq carfify that I am the Omar, OpernNG ordntharitedagent of this Business, and 1 arknmdedge that all PER.Uff Fess, <br />PENA.nes, EA'FDR ftATC1WMand/or 110M..1' CIURUES associated pith this operation mill be billed to me at the address identi6ad above as the LICrnuAT fnnRFCV for this sitr. 1a I,. certify that nil <br />infamacion pnI on this application is Iran end correct; and that all regulated acthities nill be performed in accordance nit, all applicable SAN Jotomti CouA-rY Ordinance Codes and/or <br />Standards and STATE and/or FEDEHAL Lan" and Regulations. As the undersigned mvner, opentoA or agent of the property located at t above facility/ It ress,1 hereby authorize the release of <br />any and all Tamils and om4runmental assessment Information to SAN JOAQUIN COUNTY ENVIRONMENT, HEALTH DEP Rm y as sopa os s mnilabla and al iM1e soma time it is <br />provided to me or my represmlalire ll/ gg <br />PLEASE POINT SIGNATURE �p )/ <br />APPLICANT NAME Oavid eargont // � <br />15�1- <br />TITLE Authorized Agent V / <br />20D3 d, 9 5-0 <br />