Laserfiche WebLink
San Jo <br /> DATE in County Environmental Health Dertment <br /> � <br /> // MASTER FILE RECORD INFORMATION "MFR" GREEN FORM <br /> S Anrn n <br /> �i OWNER ID# <br /> CARE# UNIT IV <br /> COMPLETE TNEFOLLOWiNGPROPERTY OWNER FILE <br /> _ WNER INFORMATION; GtEo Jt`OWNER CNteEmxr,W,l,, <br /> PROPERTY OWNER NAME I\� �I W+n+EHD <br /> col.�V p PHONE l O / <br /> 1 First MI ` <br /> Bt15wEi5 NAME V���1 Last <br /> Vw" V 1 I I I 06r/1 Vj lvF:41� SDC /TAxID# <br /> Owner Home Address <br /> rpt I <br /> City DRIVERS LICENSE# <br /> Owner Mailing Address STAT(A ZEP rG]K, <br /> Mailing Address City v <br /> State Zip <br /> CORPORATION❑ <br /> INDIVIDUAL❑ <br /> PARTNERSHIP❑ <br /> FED AGENCY❑ <br /> OTHER <br /> FACILITY FILE <br /> FACIL.[IY ID# /1l <br /> 1 Ni\ 1 p I p/I CROSS REF ID# <br /> W 0 0 1 LINTIt <br /> # INV# <br /> 7N LLOWIN 00 [5 5 <br /> Is this a NEW Business LOCATION not Previously regulatedNFO M O <br /> ONME <br /> Ls this an EXISTING Business LOCATION but a NEW TYPE oegul ted Bus ness7TAL NEaLrN DEPARTMENT? vas E3 <br /> No <br /> 1U1gllESS/FACDIIf/S,,,NAME .n Yet �. NO ❑ <br /> SIIEADDREg 23q� p <br /> SUIIE# BuswEss PHONE <br /> / <br /> A rT_ ZIP <br /> BOARD OFSUPERVLSOR DLSTRIR LOCATION CODE STAT( <br /> KEPI <br /> REYZ <br /> Mailing Address//DIFFERENIhwn FaofilyAddresr <br /> YU GL SE ( Attention:W Care OF(0ptrorfa9 <br /> Mailing Address City <br /> STATE ZIP <br /> SIC CODE APN# 3o\ 00 <br /> COMMEM: <br /> THIRD PARTY BILLING INFO: Comp/eteif Billing Pa sdrferentfrom Property Owner or Facility Operator identifiedabove. <br /> BUSwEss NAME I C� --t(�`p�, �U,�I <br /> v,�,"�t/ lfv V I Miu •o _ raPNaf/aq� , <br /> Mailing Address lW 415 S� It r <br /> lW { T ,.r/11. PHONE(�T <br /> cTlr J�V _IGLJ JrJ <br /> TE zip <br /> w.-.l(fill i for fees and charges <br /> OWNER FACILITY/BUSINESS <br /> BILLING dN f - THIRD PARTY BILLING <br /> I,the undersigned Appith t h certify that I am the Owner,Opemlo,the is l r Aalid <br /> PENALTIES,Erv£OxcEaf£MCHgRe£s and/or ROUxtYCNgxr,£s associated with this operation will be billed to meat the address harizeea A gent off as is Bann,,mid I acknowledge that all PE"a PEES, <br /> aII infacco fion Provided on this appgcafion u true and correct;and that all regulated acfivifies will be performed in accortj <br /> dance with all applicable San J UIP COUNTv <br /> Standards and STATE and/or FEDERAL Laws and Regulations. As the undersigned owneroperetoq ora ant ofthe ro r for this site. I also certify that <br /> Q Ordinance Codes and/or <br /> any and all result and environmental assessment information to SAN JOAQOIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same fime it u <br /> g p perry located at the above facaityAite address,I hereby authorize the release of <br /> provided to me or my repr t tiv � ) <br /> APPLICANT NAME ✓ EASE PRINT C8lu�ut Y I SIGNATURE J <br /> TIRE � - l ,IL(4�Q <br /> DRIVER'S LICENSE# <br /> (PHOTOCOPY REOUIRED1 <br /> Approved By D 'l 0"I <br /> V t Acrnuntin9 Office Processing Completed BY <br /> 29-02-002 April 25,2003 Date <br />