Laserfiche WebLink
San Joaquin County Environmental Health Department <br /> ^'� / MASTER FILE RECORD INFORMATION "MFR" GREEN FORM <br /> IHHARLQAR£AS FOR EHD USE ONLY DINNER ID# 60 CASEY UNIT IV <br /> OWNER FILE <br /> COMPLETE THEFOLLOWN�G7PROPERTY OWNER/NFowAT/oN; ONt urr OWNER CURREnrcyONFMett nY END <br /> PROPERTYOWNERNAME ZEEP) 12 o',J31N �O -�57200 <br /> PW MI I" <br /> euMNEsa NAMe ��� �cB(ilYv.S TNUESTmEM'r P/r�o PJt ,'d(`°((gq� $DC SECIrAz 1D# <br /> Owner Home Address �� -..iC ! 'I ) / l ORIVER's LCENSE# (`� (� <br /> Cft STATE/ ZIP `, J �1 <br /> Owner MaIft Addreee <br /> Malling Addreae CRy S,ro � <br /> 'yy/ sCA LP 95ZoA{ <br /> CORPORATION❑ INDIVIDUALINy PARTNERSHIP El FES,AGENCY❑ OTHER Ll <br /> FACILITY FILE <br /> FACILITY ID# OROSBREFID# - ACCOUNTID# INV# <br /> ���rta �Tnl 3j. 19 I `fit l <br /> COMPLETE THEFOLLowiNG BUSINESS/FACILITY/SITE/NFoRwTloN, <br /> Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEP-r.? YES ❑ NO <br /> Is this an E%IsTING Business LOCATION but a NEw TYPE at regulated Business? YES ❑ NO <br /> BUsthEsWACILYTYISITENAME FO((Mr—,z lklolluE ctF4"aQ-S <br /> SITeADDREBB 3L10(0 <br /> Ajox,rit t)C�wgRe AVE <br /> SUITE# BUSINESSPH°NELf <br /> cm S 1��'ICTaN 1J VWG STAW Cj4 ZIP 95Z� / <br /> BOAmoFSUPERVI;cgtDi TRIGT LACATIDNCODE KEYt KEY2 <br /> MaIAIg Address IfDIPFERENTfv FeelftAddm. Atterilcm:car Care Of lop#wmlJ <br /> Melling Address City STATE Zip <br /> SICCODE APN# COMMENT: <br /> THIRD PARTY BILLING INFO' Complete ifBilling Party is different from Property Owner arFacility Operator idenfified above. <br /> SusmEn NAME AffenBaR:ea-C.Of jWth mp <br /> Melling Address PHONE <br /> Om STATE ZIP <br /> forfeass and charges OWNER FACILrrYIBUSINESS THIRD PARTY BILLING <br /> BILLING AND COMPLIANCE ACIOVOWLEDGMENT I,IM1e mMeraign¢d Applicant,certify MM l am the Owner,Operarary OrAWrar4MAgen(of Mu EoaineA end I aehaowNdge the[all P£RA//fFE£S� <br /> PENALnES,ENPoRfU/£.AT CII.L¢CES and/or ROOMxCHARGBS associated with Mie operation will he billed to me at the address identifid ahme as Nw ACYorm'TAnnRaSt'forlhuaib, Ivb.tertifylhat <br /> all information prodded On this application is true and correct;and that all regulated sthvides will be performed in sevoedanec wish all applinble SAN JOAQUIN COUNTY Ordinance Codes and/or <br /> Standards and STATE and/or FEDERAL Laws and Regulatiena As M1e undersigned owner,operebr,or agent M Mt property bralod al the about fadliryhiLe address,l hereby an/lmrv<nM rtlrnat of <br /> any ash all resnlb and endrenmenml essesment inforrmtion to SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon As H is available and at the some time it is <br /> Provided to me or my re eeebtim <br /> APPLICANTNAME 2 ,��/s 1/7EPRINT SIGNATURE <br /> ✓' \\bLl 11 _ <br /> TIS DRIVER'S LICENSE# <br /> fl ll (PHOTOCOPYREOUIRED) <br /> Appmvad BYDab Ae.mmUns OlROe Processing Completed B Deb O <br /> 29-02 10/12/07 MASTLR FILE RECORD-GREEN <br />