Laserfiche WebLink
�^ San Joaquin County blic Health Services Environme� Health Division <br /> 3 ' D GREEN FORM <br /> DATE ' MASTER FILE RECORD INFORMATION "MFR" <br /> SHADED AREAS FOR EHD USE ONLY OWNERID CASE# <br /> # ✓l -. UNIT <br /> 'V <br /> OWNER FILE <br /> COMPLETETHEFOLLOW/NG PROPERTY OWNER INFORMATION.' CHEcH/F OWNER CURRENTL VON FILE wiTHEHD <br /> PROPERTY PHONE <br /> OWNER NAME D / ��(/ /Z41 <br /> L.S, ��2, ��•j/� <br /> Fvsf MI last •/ <br /> BUSINESS NAME � <br /> O SOC SEC I TAX ID# <br /> r T <br /> Owner Home Address �j��n' DRIVER'S LICENSE# <br /> City Yv�/r � O� �� 'b� � STATE ZIPQ3•z3atl <br /> Owner Mailing Address <br /> Mailing Address City State Zip <br /> CORPORATION INDIVIDUAL PARTNERSHIP FED AGENCY ElOTHEfl <br /> /.p j //' `f/ / FACILITY FILE <br /> IT <br /> FACILY ID# o l q CROSS REF ID.#. ACCOUNT ID# INV# <br /> COMPLETETHEFOLLOWING BUSINESS/ FACILITY/ SITE INFORMATION. <br /> Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DIVISION? YES ❑ No ❑ <br /> Is this an EXISTING Business LOCATION but a NEW TYPE of regulated Business? YES ❑ No ❑ <br /> BUSINESSIFACILITYISITE NAME /j,D}0-7M- V— C�/4NNIUCL/ <br /> SITE ADDRESS SUIT # BUSINESS PHONE <br /> CITY STATE ZIP <br /> BOARD OF SUPERVISOR 11_LOCATION KEY1 I I KEY2 ' <br /> Mailing Address heDIFFERENTfrom Facility Address Attention: or Care Of(optional) <br /> Mailing Address City STATE ZIP <br /> SIC CODE A # —� <br /> � PN COMMENT: <br /> THIRD PARTY BILLING INFO: Completeif Billing Party is different from Property Owner or Facility Operator idenariedabove. <br /> BUSINESS NAME Attention: or Care Of (optional) <br /> Mailing Address PHONE <br /> CITY STATE ZIP <br /> Ac7.77 DDREss for fees and charges OWNER FACILITY/BUSINESS THIRD PARTY BILLING <br /> BILLING AND COMPLIANCE ACKNOWLEDGMENT: I,the Undersigned Applicant,certify that 1 am the Owner,Operator,or Authorized Agent of this Business,and 1 acknowledge that all <br /> PERMITFEEY,PENALTIES,ENFORImtrENTCHARGEY and/or HOUM.YC//ARGEV associated With this operation will be billed tome at the address identified above as the ACCOUNTADnRESS <br /> for this site. 1 also certify that all information provided on this application is true and correct;and that all regulated activities will be performed in accordance with all applicable SAN <br /> JOAQUIN COUNTY Ordinance Codes and/or Standards and STATE and/or FEDERAL Laws and Regulations. As the undersigned owner,operator,or agent of the property located at the <br /> above facility/site address, 1 hereby authorize the release of any and all rees-usly n e ' It 1 assessment information to SAN JOAQUIN COUNTY ENVIRONMENTAL <br /> HEALTH DIVISION as soon as it is available and at <br /> the same lime itis proviria'^'* �`' <br /> PLEASE PRINT <br /> APPLICANT NAME SIGNATURE <br /> TITLE DRIVER'S LICENSE# <br /> (PHOTOCOPY REOUIREDI <br /> Approved By Date Accounting Office Processing Complete (16 1 Date <br />