Laserfiche WebLink
�+ ;ice .s."".d'",. 'i'^y,. "..,�"-", ---- � .✓r ,'x `.....5- a.:,�Z' <br /> ,- SarurrCountynv�rOnaentalrHeait''c epairtr�ent .. L <br /> ,,j�� <br /> DATE <br /> MASTER FILE RECORD INFORMATION ""MFR" �1' 17 `,T <br /> OWNER FILE ENVIROVIEW HEALTH <br /> COMPLETETHEFOL\LOWZNGPROPERTY OWNER INFORMATION: CtfECKIF Owl , �r ftaTt/EHD <br /> PROPERTY OWNER )T� n /� PHONE <br /> NAME ,d n V I J �/ l� �—i�� Ie® <br /> First MI last <br /> /1 Soc SEc/TAX ID# <br /> BUSINESS NAME /�'�J Jt �/'06 <br /> Owner Home Address �'KI©{/�_ y1{�F�o/_ it <br /> &/7Lt� T(/V f./ DRIVER'S LICENSE# <br /> city STATECA_ zIP QI�Z <br /> Owner Mailing Address <br /> Mailing Address City ✓ V (� state�Al Zip <br /> TVDF nr r11WNFDCLRP <br /> t'/IODflDAI'IMI� TNDMDIIAI ❑ DADTNFP WTD❑ FFA Ar_cury❑ r1TlIGP❑ <br /> COMPLETE THEO INFORMATZON, <br /> Is this a NEw Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ No <br /> Is this an EXISTING Business LOCATION but a NEw TYPE of regulated Business? YES ❑ No t� <br /> BUSINESS/FAQSITE NAME I _ �• <br /> SITE ADDRESS SUITE# �USINE55 PHONE <br /> 104 /sem s r��- <br /> 4z � y � �-� <br /> KEY <br /> Mailing Address ifDIFFERENT from FacilityAddress Attention:or Care Of(optional) <br /> Mailing Address City STATE ZIP <br /> slccoDE" AP <br /> ` <br /> _m_ ,.._ , <br /> sCoMMENr <br /> a <br /> THIRD PARTY BILLING INFO: CoMpiete if Billing Party is different from Property Owner or Facility Operator identified above. <br /> BUSINESSME Attention:or Care Of (optional) <br /> �. r�, ©p -,7z9C 5A) IfO6blA IC /AWP I KI <br /> Mailing Address PHONE O"� <br /> CrTY m 7X2 0 STATE n ZIP <br /> 4C=,'tYT ALozmE for fees and charges OWNER FACILITY/BUSINESS ARTY BILLING <br /> Rn.1.INC AND romp,iAYrF ArKN6w/.F mFN.T: 1,the undersigned Applicant,certify that 1 am the Owner,Operator,or Authorized Agent of this Business,and I acknowledge that 211 PERA17T FEES, <br /> PENALTIES,ENFORCEMEN CHARGES and/or HOURLYCHARGES associated with this operation will be billed to me at the address identified above as the ArrOrwT ADDRFCS for this site. I also certify that all <br /> information provided on this application is true and correct;and that all regulated activities will be performed in accordance with all applicable SAN JOAQUIN COUNTY Ordinance Codes and/or <br /> Standards and 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 as soon as it is available and at the same time it is <br /> provided to me or my representative. <br /> ,/ PLEASE PRINT <br /> APPLICANT NAME /C / SIGNATURE <br /> TITLE ��f \\\ DRIVER'S LICENSE# <br /> (PHOTOCOPY REOUIRED) <br /> y <br /> Ved <br /> BY�{ � � ;Date�'. -. .._ .� .-"� Aupting Offxe pTooessing:t.ompletUuiBY <br /> -.1... .mss <br /> �►PPro ..� cco <br />