Laserfiche WebLink
L_ Pry ,, man ion Ain:c;rountyPubfrcHealth Services_ Evi Balt - v`sia .ti <br /> �. <br /> U E GREEN FORM <br /> MASTER FILE RECORD INFORMATION "MFR" <br /> SHAPED AREAS FD EHD US ONLY �� �" °�¢ � r 5- n "' : �"' - '� :'� '3 <br /> Ow►i�[t rap UNIT IV <br /> �Gt1 D4/p��a OWNER FILE <br /> COMPLETE THEFOLLOWINGPROPERTY OWNER INFORMATION.' CHECILIF OWNER CURRENTLYpNFILEWITHEHD <br /> PROPERTY <br /> W41\� PHbNE� q <br /> OWNER NAME Cl 2 i � L4 <br /> FYst M1 last I <br /> BUSINESS NAME SOC SEC/TAX ID# <br /> Owner Home Address DRIVER'S LICENSE# <br /> City C+S��l� STATE C ZIP C� <br /> Owner Mailing Address <br /> Mailing Address City S a\m0-- State Zip <br /> CORPORATION❑ INDIVIDUAL❑ PARTNERSHIP❑ - FED AGENCY❑ OTHER❑ <br /> d 3 FACILITY FILE <br /> F11GIlY1Y ID# ., u 4�4-; �' �`w' sa• fi'->',� 'wOrtC>O-= f �g <br /> lROSS EE D '"�P"�' '71z�' Y �it zf%�• : ,�3,,rt ,u �. , <br /> COMPLETE THEFOLLOWING BUSINESS I FACILITY I 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 7 YES ❑ NO ❑ <br /> BUSINESSIFACILITYISITE NAME <br /> SITE ADDRESS �\ i i SUITE# BUSINESS PHONE <br />"- CITY �`1 � ��/ y�Y\ � STATE 21p <br /> 111011111 V.,1 <br /> _BOARD OP SUPERVISOR ,'�s _ m a� Ky_r <br /> + Lin, <br /> _C9.991122,21a � <br /> Mal ling Address IfDIFFERENTfrom FaciityAddress ; Attention: or Care Of(optional) <br /> Mailing Address City STATE ZIP <br /> y xM<., m . �- +3'° <br /> SIC CODE APN#. ,. ,. x - °COMMENT: n r <br /> >*�. '.�+✓, -'.x„�, %:VSs <br /> THIRD PARTY BILLING INFO: Complete if Billing Party is different from Property Owner or Facility Operator identified above. <br /> BUSINESS NAME ,9d Z� /fm Attention:orCare Of (optionaall)y <br /> rA <br /> Mailing Address 2 3 I _ �0.� 14. ;� U'z Ai PHONE <br /> CITYpWt''p� 7 o S7A7E ZIwP <br /> ArawNr_AaaRr_s_s for fees and charges db1W I y FACILITY/BUS]NESS' 42 .42 j <br /> THIRD PARTY BILLING <br /> BILLING AND COMPLIANCE ACKNOWLEDGMENT: 1,the unde certify that I am the Owner,Operatoror Au ess,and1 acknowledge that all <br /> P£RdffT FEF-v,PFN,4LTIEv,ENFORCEMENT CHARGES and/or Fir) RLL-4peuw <br /> ssociated with this operation will he billed to me at the address identified above as the ACL'ouN"rAnnREYS <br /> for this site. l also certify that all information provided an 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, I hereby authorize the release of any and all results and environmental assessment information to SAN JOAQUIN COUNTY ENV[RONMENTAL <br /> HEALTH DIVISION as soon as it is available and at the same time it is provided to me or my representative. <br /> PLEASE PRINT <br /> APPLICANT NAME SCX ���� SIGNATURE <br /> TITLE DRIVER'S LI NSE# <br /> (pN{IInCOPY REOt1lRED1 <br /> Ac <br /> VIP' <br /> ()ffitie:Proaesslri Corr/ feted;P � pste,. 4 , <br /> x /y <br />