Laserfiche WebLink
San i0quin County Environmental Health In <br /> DATE <br /> VA� MASTER FILE RECORD INFORMATION `fMFR" �u irvbRM <br /> SHADEDARFAe FOR END BEO OWNERIW CASE 0 6 UNIT 'V <br /> ri IP <br /> GWOD15g�lb <br /> OWNER FILO <br /> COMPLETE 7HEFOLLOW/NG PROPERTY OWNER/NFORMAT/ON.- ct.,,"64� IKTNEHD <br /> PROPEmr OWNEp NAME PHONE <br /> First MI Last <br /> BusNEss NAME C _.�1. ��N 3Oc SEcfTAXIDN <br /> OwmrHume AddrneeC-LO <br /> 4 L�� DRNEp'e LICENSE# <br /> CRY to oU STATELa <br /> C%tR 0) <br /> Owner Wiling Aldraes Ste' <br /> Melling Address CILy State ZIP <br /> CORPORATION ho meest.❑ PARTNERSHIP LT FEDAOENOY❑ OTHER El <br /> FACILITY FILE <br /> FACILITY ID# 3 CROss REFID# Acoouw 1D# INVII 1 11 <br /> COMPLE>F THE FOLLOWNG8USINESSIFAC ILITYISITE/NFORAMnoN• J 1 <br /> Is this a NEW Business LOCATION not previouely regulated by the ENVIRONMENTAL HEALTH DEPT.? VES ❑ NO LAs <br /> Is this an BUSTING Business LOCATION but a NEwTVPE of regulated Business? YES ❑ No D9 <br /> BusaEssffimaTTYISin:NAME �I <br /> SITE Altagees ` I 1 v e—r 0 K'e SUITE# Biss Ness PHow <br /> Cm Lodi STATE ZIP <br /> CA 95240 <br /> BOARD OF SUPERVISOR DISTRICT LOCATION COOS KEPI KEY2 <br /> Melling Address ND/FFERENTfrom FscltifyAddross 1420 S. Mills Aeu,e--StU—K Attention:or Care Of(optional) <br /> Mailing Address City Lodi STATE <br /> CA LP 95240 <br /> SIC CODE APN# Ct>,MrNr: <br /> THIRD PARTY BILLING INFO: Complete ifBilling Party is different from Property Owner orFacillty Operator identified above. <br /> BusNEss NAM` Neil O. Anderson &Associates, Inc. Adantlon co-Care Of top,Yonelf <br /> Mallingfiddr.aa 902 Industrial Way PHONE 367-3701 <br /> Q Cm Lodi sTATE CA z>P 95240 <br /> ACGPTtN7AOGBE35 for fees and chargee OWNER FACILITYBusINESS THIRD PARTY BILLING <br /> BD,WNC AND COb I6 aAgmrn EDchRrcr: t,the undersigned Applicant'certify that l am the Owes,Operator,or Authorized Agent of this Business,and l ackmowiedge that all PFRMrrFEeq <br /> PHfld =,ErvPORCEHaM'CI A:V and/or Rorwr Ct Es associated with this operation will be billed to me et the address identified above as the ACCOUNTADDR£knforow this siha t also certify that <br /> nil information provided on this application is true and correct;and that all regulated activities will be performed in accordance with oil applicable SANJOA m CO11Nr t Ordinance I a Cada and/or <br /> Standards and STATE and/or F EDERA Laws and Regulations. As the undersigned owner,operator,or agent of the property located at the above facility/site address,I hereby rdinan authorize the release of <br /> any and all results and environmental assessment information to SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTR DEPARTMENT ns soon as it is available end at the same time it is <br /> provided to me or my representative. <br /> APPLICANTNAME Abby Racco PLEASE PRINT SIGNATURE <br /> TITLE Project Scientist DRIVER'S LICENSE# <br /> 11✓✓ _fPXOTOCO%pEOBIREDI <br /> APpvesa By lo O Accounting Office Processing Completed ay Day <br /> 29-02 10/1]/09 <br /> MASTER FILE RECORD-GREEN <br />