Laserfiche WebLink
San Joaquin County Environmental Health Department <br /> GREEN FORM <br /> DATE <br /> 'f�j d`j MASTER FILE RECORD INFORMATION "MFR" <br /> oPMnnee nmv OWNERID# /,a_ CASE III UNIT IV <br /> OWNER FILE <br /> COMPLE7F 7NEFOLLowiNG/PROPERTY OWNER INFORMATION: CN£ortF OWNER CURRENnYMEzIr WLnL END <br /> El <br /> PROPERTY OWNER NAME / /.L B <br /> l/1 1 First I M1 I q Last <br /> Business NAME /v(� :51V/�A� //i V] l/t/� l--'s SMSaC/TAXID# <br /> Oiler+ m � <br /> Hoe Address C �[/ Q�"b(Jy Da R's <br /> �LvElJNssAt /� <br /> CRY S l `/� STATE Cu4 zap "7 Z <br /> Miner Mailing Address <br /> Mailing Address City mate Zip <br /> MMEDEO an �r <br /> ConronATTON❑ INDMDUAL❑ PARTNERSNP❑ Fm AGENCY❑ OlIER6l_ <br /> FACILITY FILE <br /> FA--ID# 11(1� CROs REFID# AeeourR ID# a, 8e(JO ' INV# <br /> C011111PLETE 7NEFOLLOWING BUSINESS I FACILITY SITE 1NFyRAfA77oN., (E <br /> Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? yea ❑ No�- <br /> Is this an EXISTING Business LOCATION but a NEW TTY��PE Of regulated Business? r� yes; ❑ No <br /> `( <br /> IJttsinsss/FAtnm/SITE NAME / / Q Eler 'C <br /> SmADDnEss -3�5 "� VV ��C/y s1 # /I Busomss;PHONE <br /> CITY -e//^^. 4 STATE�[.J Zb /A'C�/20" <br /> BOARD OF SUPfRvisOR DISTRRT LocwTION CODE KEPI KEY2 V �� J L/ <br /> Mailing if IFFEREVrfiW"Faci/itrAd Ea;ar Athention:or Care Of( Q <br /> bac 4 c 5t �cErrc /`�,/(O B24. TO. cy r6 rcrhs�v�� <br /> Mailing Address CRY ./ )titFv�1/l J l Q STATE C4 ZIP C71II <br /> SICCI. OO t�5.&I MN# 13�32b�2— CDMMEM: ! � <br /> THIRD PARTY BILLING INFO; Complete/f Billing Party is different from Property Owner orFacillty Operator identified above. <br /> Buswsss NUAE / } 1 j � I e r o ^ ! ntlon:orUre Of (oplivr I <br /> ��/ V n /� IIiXIYlJ-Gn <br /> Mailing Address 6-0 od v—d le'n PHME gfG/i�// /G�'/e2 I <br /> CITY (J`((//�\ V (/� r/ SfA,E /C! 1(`T ZIP <br /> AccoO ADDRESF for fees and charges OWNER FACILITYIBUSINESS l (�TTHIRD PARTY BILLING <br /> B h h r ANn COMP rANCv Ar¢Nmvi Pm:MFNTI 1,the undersigned Applicant,certify that 1 am the Owner,Operator,or Authorized Agent of this Business,and I acknowledge that all PERNIr FEES, <br /> PENALTIES,EAMnciWENTCNARG£S and/or HOURLY CHARGES associm cl with this operation will be billed to meat the address idenfifird above as the ACC0trNTAnnR"5 for this site. 1 also certify that <br /> ail information provided on this application is true and correct and that ail regulated activities will be performed in accordance with all applicable SAN JOAQUIN COUNTY Ordinance Codes and/or <br /> Standards end STATE and/or FEDERAL 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.,soon as itis available and at the same time ht' <br /> proOded to me or my representative./� %�///� <br /> APPLICANT NAME n N ,(J�r I',//Pu'ASE PRu+T SIGNATURE ,�i,`, L ' v <br /> TITLE L� f.IL DRIVERS LICENSE# <br /> Try IlawToeolrr AEOUMD) <br /> APgoved BY Date Accounting Office ProceWsq Completed BY Dade (� <br /> 29-02-002 April 25,2003 <br />