Laserfiche WebLink
MQW,/'1W <br />NLIV 2 0 2009 <br />San Joaquin County Environmental Health DepartmenINVIR HENT HEALTH <br />DAA 11 MASTER FILE RECORD INFORMATION "MFR" i''E €P��'I"ES <br />Sworn uo.wcun ... .. OWNER ID#awp0�4�a91 • UNIT IV <br />OWNER FILE <br />- — - <br />PMDPnnToWRER NMIE <br />ar.Wr rctc1 r V W ryCK <br />c) PAL <br />/HFORMATIpM; <br />raEvrtP <br />W 14 T <br />OWNER Ev##EIrTLravEar tn»r END <br />PHONE <br />Frsf <br />M1 <br />Last <br />EROSS REE ID# <br />IRIIDtat NM1E CA MAT Fo Rw6-:( <br />Tart gco <br />SWSK(TMM* <br />}, <br />oWtw riaRe Atddres I a� ` , FI rzs r s 1 <br />DRN6t'FLlfas[# <br />°" <br />STATEOA- <br />m 9S�2c� <br />OWear %% Aau <br />Madt <br />MRIIRD Mares City <br />Slate <br />ay <br />CnR+oanson ❑ TNOrvmuu ❑ <br />PARTtQp5tlm ❑ Fm AOrNcv ❑ OnER ❑ <br />IS this a NEW Business LOCATTQN not Previously regulated by the ENyAEONMDrtAL HEALTH DEPARTMENT? <br />Is U$ an E1aOuKi Business LOCATION but a NEW TYPE Of Regulated BusiOe%7 <br />Yes ❑ <br />YEs 11 <br />No ❑ <br />No ElBwR <br />IFAI ,SIR Nam, C <br />e ruc <br />Sm ADDRaE 3C�3 �"�R <br />FAaury IDx <br />foo <br />EROSS REE ID# <br />AT[ <br />ACCOUMID# <br />�pp3569b <br />INV# <br />IS this a NEW Business LOCATTQN not Previously regulated by the ENyAEONMDrtAL HEALTH DEPARTMENT? <br />Is U$ an E1aOuKi Business LOCATION but a NEW TYPE Of Regulated BusiOe%7 <br />Yes ❑ <br />YEs 11 <br />No ❑ <br />No ElBwR <br />IFAI ,SIR Nam, C <br />Sm ADDRaE 3C�3 �"�R <br />s1mEx <br />Bll5D1ES PxoxE <br />t]rr <br />zSci�sa N <br />AT[ <br />zv <br />eowoa SorERvson DaTR¢r <br />LOGnION COVE <br />Kiri <br />K"2 <br />Mallitg Nates ffA1" #EA?#pn AKMIYAddrus <br />Attention: or Care Of (apelrvuQ <br />Mailing Add es City <br />SEATE <br />ZIP <br />SIC COR APN8 <br />COMNFNI: <br />THIRD PARTY IBILLJNG INFO: COmpLIteK Billing Party B dltfeirentfrom Property Owner or Facility Operator IdendfiEd above. <br />eosntEu na+R i\�N0�1 v\t M�d.,i"(`y S�i'�V IeQtS ��+< Atmrtlo\:,,Cate Of (wacvof) <br />Mailing Addtaa <br />�OZZ N\Ai?P�i'\3R STi "'?�e� C�.�W}� SSQ113 attoNe S�J-3yZ 1333 <br />ct <br />STATE Zia <br />for fees and charges O _ (THRID(THRIDPARTY BIUJ; <br />WNFR FAalmBuslNFss <br />Rn�txr. Axo rnerr �.xrr Arux o- -:1, the undeniEned Appbrant, relfy Bull.. the nrr, OPermw, or Avrborited Agent of thea Bushtse, and e—Wt.1l PEAMMFEES, <br />PEkltnEs,Erv»NwEArENrCNARcrsamor MOURtrOuacrs auoeiafed Witt Mla openrion weal D<Hgedmme at the a ddrmidmtiBedsbo wtbe Arrnn Annacrrforthetlte Iaho certify mat <br />U iafonoaW oa M <br />Noo Peovid b appihadon la true Rod correct; arM treat .11regulated actlKti. wig be perforvNd L anordanu with all applicable SAN JOAQUIN COUNTY Ordinance Coder and/or <br />Sundaes aM STATE and/or MERAL Laws and RcEWaEwr. A, We uudenieoed owner, operator, or ateat of Me property located strive above fxuityhit ddreu, l hereby aueborlee be release of <br />any and all result and mvironowntal t..t ofoneaNnn to SAN JOAQUIN COUNW ENVIRONMENTAL HEALTT EPARTMENT u soon at It Is available and at Me sortie tune it it <br />providM to tie or my repreeanpve. <br />APPLICANT NAME �`��� Ptcav PRINT SIGNATURE <br />