Laserfiche WebLink
q q San Joaquin County Environmental Health Department <br /> DATE MASTER FILE RECORD INFORMATION frMFR" UNIT GREEN FORM v <br /> Ste•=-E�l OWNERIO# II NI II I`a <br /> CASE# V <br /> OWNER FILE <br /> COAIPLETETHEFOLLOW/NGPROPERTY OWNER(NFORMArw v. CNecnrF OWNER CURRDi roNnaelnrx EHD <br /> PAnPEFI'/OWNpINaME PHONE O j 2q1- <br /> 00 <br /> ('FLeI 1 !A/ toil <br /> BV91NEiO NAVE C\ v cat- I_0.�r1 CQ <br /> y BocSeolTa l09 <br /> Owner Homo Addrom n DIEVER'a llcOme# <br /> 390 Towne C" Drwi-- <br /> city "AVap SrATE CA m 95330 <br /> Ownnr MVIIInOAddraaf <br /> Some ae obo+te <br /> Ma111nBAddroa CRy stale Mp <br /> COnPonAllorl❑ IxarvlouaL❑ PpInNEXixm❑ FEn ACENn <br /> Irk( /' OTHBr <br /> (o(DD FACILITY FILE aFiEut `.. <br /> FneartY lD,Y �Ge_sJ_ CPoae REF IDX Aeeoulrtl0# <br /> COMFLETPTHEFOLLOW/NG BUSINESS/FACILITY/SITE/NFORAIATION: <br /> Is this a NEW Business LocamoN not previously regulated by the ENVIRONMENTAL HEALTH Be".? Yes ❑ No <br /> Is this an E%IsnNa Business LOCAmON but a NEW TYPE of regulated Buslness7 Yes ❑ No ❑ ' <br /> Bu91NIiSVFndtm/Site NAup a a L, RZve, rk AJor4,l,, APA/ Iq/-33o-IO <br /> Srte ® <br /> AoaAs (boot Soo-1' L 4-kro Rd. Sort" OuslnEss P,t uE <br /> d 9Nl-7 <br /> Cm r� <br /> a-lanrafppp' G`"r Cll� z' y 53?0 <br /> BomaOFSOPEAVIDaa ObtiilCT Y LerATON CODE KM <br /> MnHinD Addrav IrO/FfEAENTfmmFPd/1fyAddrocs Aitvnllon:or Com Of(aPUonoQ <br /> IAolilnO Addro:s City 390 -FOGJneT!STAnr <br /> a to CV} riSp330/' <br /> SICCoo=_ APN# '�/ ry�Q I� Commern //tri r�(F dC(-v/ +, <br /> THING PARTY BILLING INFO: Completeli(Billing Party is different from Property 0 r orFawcility Operator idenGfiedabove. <br /> BuaiNEV N.w! `'_ •-/ Attenaon:erCero Or(Pptlena// <br /> maillrj Address `)I_O3o 14(a P..". F��l j &A!— 5883 <br /> Car S4Dck-40�, STATE CA /z" 9 5;�o l <br /> iEigtL L9OOAE55 for fees and charges OWNER FAcrury/BUSINEss THIRD PARTY BILNC <br /> Rua ler+u [ + A I,Iheundenlgned APPll.nl,!!Tilt,lhailan the 0lrneq Op.•.mAvr.6n#nrisd.lg.•mofth6 Wnlnrn,andlachnmdNCe Nal all Pf2nn PE[s. <br /> !'e.+veno,GmnrcvuTC2meLSnndICNldunaYONIalfltrada¢J allh 1116 vpemdvn alit Le hilted lC me al the addmsldcnadcJ ahmxmllrt rlanrrNr,InneE[i for lldadle talo waifs lint <br /> aR Infarmativn R.TIJed vn d16 vpp4udan 6 Inc and.,reel;and Thal all m.falcuaeUHdv arl ac Performed In v.aninn.nllb all nPVl6a61c Sax Ja)Ou1N COCNn'ONimma Gm6a angor <br /> $Nndardi and STATE amt/vr FElCn\L Lm+n vml RcCuladola.N Iha unJenigneJ mmu,ape.lvA ar nCcnl of the P.Peny Ivrnlvi vl Ibv uhvve faiplyAlly addmA 1 Irtrthr auNurlav Ilse Kram of <br /> any and all readu and rav'iranlRnl.a1 canava nl Infarmadon In SAN JOAQUIN COUNTY ONWIRON\IFMAL HEALTH DEPARTMENT ns ss Ion Rr 11 6 arNlabte amt al it..5..a Ilmr If b <br /> p.vWullamcarsay rcarornlmhr. <br /> APPLICANT NAME1 ��(/'�� II � <br /> ��ar;ll)�. Vd16kx! p�7 SIGNATURE <br /> TRIP DRIVER'S LIC NE <br /> NE SE#�� �'vM'{�Jak.r Noa..�Gbtil <br /> r GAr (PHnraCOPY ReQUIREO) <br /> ApO�•od OY Dpb Ac. d OIII P V Cp 1 rtl�BY 0 b <br /> 5z 06 <br />