Laserfiche WebLink
San Jo �in County Environmental Health De 'tment <br /> QATECs;' _ ��ORM <br /> MASTER FILE RECORD INFORMATION "MFR" <br /> OWNERID# CASE# UNIT IV <br /> OWNER FILE <br /> COMPLETETNEFOLLOWINGPROPERTY OWNER INFORM.arrON:J� CH CKIF OWNER CVRRENTL YONFILLE��WlTH EHD <br /> PROPERTY OWNER NAME S I� PHON C7\� Y <br /> First M, J It J(J <br /> BusmtEssNAME finer Sev o,1S 64.0 5 a SOCSEC/TAxID# <br /> 0t7 W <br /> Owner Home Address (' -) � [f,(J4=15� � DRrvER S LICENSE# <br /> city V SPATE ZIP <br /> Owner Mailing Address <br /> `Q. <br /> Mailing Address City State Zip <br /> TVP¢nr• wNFRm4ra <br /> CORPORATION❑ INDIVIDUAL PARTNERSHIP❑ FED AGENCY❑ OTHER❑ <br /> FACILITY FILE <br /> FACILITY ID# CROSS REF ID# daz 05�5 ACCOUNT ID# 2 l CINV# <br /> OMPLETE THEF LL M NFO O �J �J 1a <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 <br /> BDSMESS/FACnXrY/SIrE NAME ,.�r P Y! <br /> SITE ADDRESS r SUITE# BU.SIN;;PHONE <br /> CITY -.�.� yl V� STAT ZiP <br /> BOARD OF SUPERVISOR DrurRICT LOCATION CODE KEY1 KEY2 <br /> Mailing Address ifDIFFFREA/rfrom FacslOAddrassAttention:or Care Of(opffonal) <br /> ISo�l LJr� <br /> Mailing Address City STATE ZSP <br /> [!�CODF APN# COMMENT: <br /> THIRD PARTY BILLING INFO-. Complete if Billing Party is different from Property Owner or Facility Operator idem ted above. <br /> BusmEss NAME A—) h'�&e) Gf-0 <br /> V1I ,�� AtWntion:orCare Or (optional)Mailing Address wIt {��-7 ( � �/� r �1� PHONE <br /> CITY5 00c STATE ZIP <br /> olc=,(A rA^�for fees and charges OWNER FACILITYIBUSINESS f THIRD PARTY BILLING <br /> BILLING AND Q3MPTjANr.T ACKNOWLEDGMENT; 1,the undersigned Applicant,certify that I am the O?mer,Operator,or Audeorized Agent of this Business,and I acknowledge that ad PERMIT FEES, <br /> PENALTfm,ENFORCEMENT CHARGES and/or HOURLY CHARGES associated with this operation will be billed tome at the address identified above as the ACCOUNTAUng Ftc for this site. I also certify that <br /> all information provided on this application is true and correct;and that all regulated activities will be performed in accordance with aR 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 DEP TMENT as soon as it is available and at the some time it is <br /> provided to me or my representative.` PLEASE PRINT <br /> APPLICANT NAME �( ��n Tin' �/��� ..� SIGNATURE <br /> TITLEG } DRIVER'S LICENSE# <br /> f (PHOTOCOPY REOLIRED) nr� <br /> APPS aY Date Accounting Office Processing Completed By Date 1 L I b <br /> 29-02.002 April 25,2603 <br />