Laserfiche WebLink
San Joaquin County Environmental Health Department <br /> DATE MASTER FILE RECORD INFORMATION "MFR" GREEN FORM <br /> _nwD UNIT <br /> IV <br /> OWNER FILE <br /> COMPLETE 77IEFOLLOWINGPROPERTY OWNER INFORMA770 CHFCKr OWNER CURstasunrONtal£WM END <br /> MAdd� <br /> ER NAME <br /> PHONE <br /> First Ml Last <br /> SOCSEC/TABID# <br /> Address <br /> DRIVER'S LRIIIEE# <br /> STATE Z0, <br /> Address <br /> ss City State Vis <br /> TYUEnanwNFAan? <br /> UMBYMATIDN❑ INDMWA El PARTNE�❑ <br /> FED AGENCY❑ OTHER❑ <br /> FACILITY FILE _ <br /> 'FA IXyfY ID# CROSSREFID# j ACCOUNT ID# INV# <br /> ETF E LL WIN N R A N' <br /> Is this a NEW Business LOCATION not previously regulated by the ENv[RoNMENTAL HEALTH DEPARTMENT? YES ❑ No ❑ <br /> Is this an EIDsfING Business LocATIoN but a Nbw TYPE of regulated Business? Yes ❑ No ❑ <br /> BUSMM/FACDIfY/SIZE NAME <br /> SIn1AODBEss <br /> $DIfE# BIl5TYess Pt10NE <br /> Cm <br /> STATE Zhu <br /> Mailing Address h'DIFFERENTTran FadlifyAridtess Attention:or Care Of(optional) <br /> Mailing Address City STATE Zm <br /> THIRD PARTY BILLING INFO: Complete if Billing Party isdifferentfrom Property Owner or Facility Operator identified above, <br /> B15n1E55 NAME Attention:orCare Of (optional) <br /> Mailing Address PIanE <br /> Cm <br /> STATE IJp <br /> ACcQLWLAQQR&ee for fees and charges OWNER FACILITY/BUSINESS THIRD PARTY BILLING <br /> B C A : 1,the undersigned Applicant,certify that I am the owner,operator,or Authorized Agent of this Business,and I acknowledge that all PERMITF£FS, <br /> FEN ns,ENFORCEMFNr CHdR and/or RODBLYCHJROFs associated with this operation will be billed to meal the address identified above as the ACWUn ADD rV far this site. i also certify that <br /> all information provided on this application is true and correct{and that all regulated activities will be performed in accordance with all applicable SAN JOAQMN COU Ordinance Codes and/or <br /> Standards and STATE and/or FEDEML 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 representative. <br /> APPLICANT NAME Kruse PRIM <br /> SIGNATURE <br /> TITLE <br /> DRIVER'S LICENSE# <br /> (PHOTOCOPY REQUIRED) <br /> Approved BY Date Accounting Office Rocessirg fzu pleted BY Date <br /> 29-02-002 April 25,2003 <br />