Laserfiche WebLink
u <br /> li �I� I{hsSYvlces t EfiliFohelHe0Ith <br /> @,U-Ai ;DiGisitin It .f 'i Ii' <br /> GREEN FORM <br /> DATE 10 lj-7 �Q MASTER FILE RECORD INFORMATION rrMFR99 <br /> S.S4EatflEl9 FCS.Et19Sr4�0ST - OWf;Eax ��. . , 1' :, x:� r1> F ; UNIT IV <br /> OWNER FILE <br /> CNecRiOWN <br /> ERCURaeN <br /> rzvoNFuE <br /> HirNEHD <br /> COMFLETIFTHEFOLLOWINGPROPERTY OWNER INFORMATION. <br /> PROPERTY -� IT /�AV•r• Wy7110 PHONE GRIF _ l� 5- <br /> --OWNER NAME ✓(S t"F— <br /> Frd MI /V <br /> BUSINESS NAME f',IqMEL,0Dj` 1_LJe, 14S,01ASST14.1"- SOCSECITAXIDN <br /> Owner Home Address • / 1 S 9 So r/ <br /> 104X DRIVER'S LICENSE N <br /> CITY S I O`• '�� C�- STATE ZIP <br /> Owmr Marline Addrao <br /> Mailing Address City Startle Zip <br /> CORPORATION INDIVIDUALO PARTNERSHIP❑ o,1 `1�v FEO AGENCY OTHER <br /> FACILITY FILE <br /> , . r i <br /> 1' i ��n° ' iAaE3�Iilt"��' �n� uav, <br /> COMPLETE THE FOLLOW/NG BUSINESS I FACILITY If SITE INFORMATION: <br /> IS this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DIVISION 7 YES ❑ NO <br /> Is this an EXISTING Business LOCATION but a NEW TYPE Of regulated Business? YES NO p <br /> BUsiNESsIFACILITYISITE NAME S J ^ /� �L�L ff <br /> SITE ADDRESS POO �C•[}pC` _/_ /[� ----------- SUITEN BUSINESS PHONE <br /> CITY Lp 05 /VG /Y I/K C! STAIV/Av'ZIIP <br /> - CL/T p rpt <br /> l. F .. , t? � . T ". 41o*t.`t, <br /> t '� <br /> Mailing Address IfDIFFERENT from FacilityAddress Attention: or Care Of(optional) <br /> Mailing Address City STATE Zip <br /> IIH FSR €m <br /> THIRD PARTY 13ILLING INFO: Complete if Billing Party is different from Property Owner or Facility Operator iderftrYfed aGove. <br /> BUsINEss NAME Attention:or Care Of (optional) <br /> Mailing Address PHONE <br /> CITY STATE ZIP <br /> ACCOUNTAODWS for fees and charges OWNER FACILITYIBUSINESS THIRD PARTY BILLING <br /> BILLING AND COMPLIANCE ACKNOWLEDGMENT: I,the undersigned Applicant,ceHify,(hat I am lite(Tuner,Olrerntnr,lir Authorized.ARent of This Ifusinesa,slid 1 AcknnwledLe Ihnl all <br /> PF.MITFEEe,PRNALT/FT,ENFORL'Ft1FNTCtrA6oFc and/or HOURLYCHARG TAVIOCIAled with this operallml will be billed to roe at the nddress Wenligcd above as the ACL'ouNr AinnuZ <br /> for this site. I also Certify Ibal ng hlfornlation provided on this application H(me and Correct(and that all reRalntal activities will he perforaied in arcoldrin Ce with all AppliCAMe SAN <br /> .JOAQUIN Cour'rie Ordinance Cod"and/lir Standards and STATE and/or FEDERAI.LAws and Regalallons. As[lie Irn11enigned owner,openler,P^^^^^ '-"- '-- - -1 Tire <br /> above fadlity/slte address, 1 hereby authorize IIIc release. of any and all result] rind environmental isseS9ncid Information to SAN JO/, r r'"L <br /> I I EALTII DIVISION as soon a 11 is available and of the same lime it Is proved to me or my reprrsentalive. <br /> LMI PLEASE PRINT <br /> X APPLICANT NAME Q d'1 N R Sero h ��DiE LIJCC/(fir SIGNATURE <br /> M�Nn�� DRIVER'S LICENSE <br /> TITLE ' l „l (PHOTOCa <br /> OPY FO111RFD1 <br /> l 6�H� '��^ �' �` A��l�iiflK 'floe Fdf ese ri coni Flee"d 9 � r.x Dele 9 <br />