Laserfiche WebLink
_ Sar Joaquin County Environmental He �eNartment <br /> DATE r,h /gyp �p uYASTER FILE RECORD INFORMATION "MFR" GREEN FORM <br /> SHADED AREAS FOR EHD USE ONLY OWNER ID# CASE# UNIT IV <br /> OWNER FILE <br /> COMPLETE THE FOLLOW/NG PROPERTY OWNER /NFORMAT/ON.' CHEcKIF OWNER CuRREAtrcroNFtLEw1TH EHD <br /> PROPERTY OWNER NAME l-. + / //' ^ PHONE IVA <br /> First MI C. (( Last <br /> BUSINESS NAME SOC SEC/TAX ID# <br /> _ <br /> Owner Home Address J!� DRIVER'S LICENSE# ,!� <br /> City STATE `!A ZIPN �` <br /> Owner Mailing Address ! I �, /t O 7sU /"'Y /� <br /> t7 W e S <br /> Mailing Address City S�, L / �O^ State (fA Zip !� 52,D <br /> PF OF OWNERSHIP <br /> CORPORATION❑ INDIVIDUAL❑ PARTNERSHIP❑ FED AGENCY❑ OTHER❑ <br /> FACILITY FILE <br /> FACILITY ID# CROSS REF ID# ACCOUNT ID# INV# <br /> O C�U')-tl ti 3 b�v a 0 <br /> COMPLETE THE FOLLOWING BUSINESS/FACILITY/SITE INFORMATION: <br /> IS this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH YES ❑ NO ❑ <br /> IS this an EXISTING Business LOCATION but a NEW TYPE Of regulated Business? YES ❑ NO ❑ <br /> BUSINESS/FACILITY/SITE NAME PSP 771 <br /> C <br /> SITE ADDRESS12 D �� ��� ��� r SUITE# BUSINESS PHONE <br /> U r., C Va i <br /> CITY GJ� / STATE/// ZIP 5�0 <br /> � Ci n v v <br /> BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEY1 KEY2 <br /> Mailing Address WD/FFERENT from FaciiityAddress Attention:or Care Of(optional) <br /> Mailing Address City STATE ZIP <br /> SIC CODE APN# COMMENT: <br /> THIRD PARTY BILLING INFO: Complete if Billing Party is different from Property Owner orFacility Operator identified above. <br /> BUSINESS NAME Attention:ot-Care Of (option/) <br /> Mailing Address // O [PHONEo - - 6 <br /> CITY $jATE LP �S <br /> 6 <br /> ACCOtwLAUDRE¢c for fees and charges OWNER FACILITY/BUSINESS THIRD PARTY BILLING <br /> BILLING AND COMPLIANCE ACKNowLEDGMENT: 1,the undersigned Applicant,certify that I am the Owner,Operator,or Authorized Agent of this Business,and 1 acknowledge that all PERMIT FEES, <br /> PF„ti4Lr/Es,ENFORCE,HENT CHARGFs and/or H0URLYCn4RGFs associated with this operation will be billed to me at the address identified above as the Accou'yTADDRESS for this site. I also certify that 211 <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,1 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 /> APPLICANT NAME / PLEASE PRINT SIGNATURE � <br /> TITLE DRIVER'S LICENSE# <br /> _ <br /> (PHOTOCOPY REQUIRED) <br /> A roved 6 t <br /> PP Y Date Accounting Once Processing Completed By <br /> 29-002 April 25,2003 ` <br />