Laserfiche WebLink
11/13/2003 09:04 9497231854 FREY ENVIRONMENTAL PAGE 11/1 <br /> San Joaquin County Environmental Health Department <br /> GREEN FORM <br /> DATE I I 12103 MASTER FILE RECORD INFORMATION YAMFR" <br /> = > RI°" DIdZn3 7 UNIT IV <br /> -- OYIMERFILE- - <br /> MPLFm TNEFOLLOWINGP P 1Y OWNER IIVPoRMATIOJY' OrEn'fF OWNER O/RRfM1YOMFILEWIyTI EHD <br /> PaoP,tTr Owrtu HANE PNarre <br /> !� First MI` y Lest <br /> BusaaEss NANE 1\ 1 Ep, -TRUCK INC. SKSEC/Tam# <br /> Owner Hotree AddR% DBwEA's LICENSE R <br /> CRY STATE ao <br /> owrarMe"AddressF�a0. a0y, 0-n�11q <br /> Mailing Address CRY YN\i Apr)1 zip "j31U2 <br /> CdnPaaallON� INDMCUAL❑ PAmr<uHm❑ F-ECADeR[Y❑ DTweR❑ <br /> FACILITY FILE <br /> FMILtrY IDN 0/c505D UDss REF ID# Aeca»r.ID sit Err L5 <br /> I""N <br /> rtjfMLowLyG ' FACILITY/ SITE INFORMARONC <br /> is ttNs a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENr7 Yet ❑ No <br /> Is this w ElasTm Business LOCATION bul:a NEW TYPE of regulated Business? YFa ❑ No <br /> Busmen/FA(]uTv/Sire Name IZ'��E2 T'9,LJC,K g -1 "`— <br /> Sm ADDREn -J( "b-75 c.R•E�K I�, CZ.IV sum# 2dBus,nFSB�5- 3213 <br /> 4TY ac.1�' SATEC 2ID °15215 <br /> BDMDOF$WERV60R DLSIRIR LOCATION CORE KM 1QY2 <br /> MaiHreq Addles dOIFFERENTNmr Atd/#TA1dl6s Attention:a caro Of(apMdnhl) <br /> Maning Addre%Gty STATE 22m <br /> sic CODE APNN '- 13— '510 C11 °own <br /> THIRIR PARTY BILLING INFO: Cornplele if Billing Party is di(fermt from Property Owner or Facility Operator ldenfiW above. <br /> &,a2S KN r=REY Attention:Or Care Of (eptYdraar) <br /> �,av tRolirnEraTRT�, i'JG. EvgY.1 a2wE-rr <br /> Maglny Addres aS11 A RTA-FAY5i-t'E AVE. PM0Ne qAA--1a3 - 1(.4 <br /> CITY IJEWPORT beAeiA SrATe^ r, ap GlL(0U <br /> AQ=MTAR0BLG'for fees and charges OWNER FACILITY/BUSINESS lr( THIRD PARTY BIW <br /> nn r xr..un comps i.vre Arveawt aw:mnvT; I,the undenigne d Appllrant,aYti y that 1 am the Owne,,OpeMor,or Aadrnrhed AgraL of this Bu l aeluewkdte that dl Pawn,FEE <br /> PENALTIES,FNFOKEA/ Ceidn r anNor HOURLY CILAAGFS airoelated with this operation will be bided to meat the address Identified ahnve as the ALrol T,ft as c foe tMs ena. 1 also drily th. <br /> all Information provided on thin application Is true and correct;and that as regulated ectivllka will be performed In secordame with all applimbh:SAY JOA00,1 Cam Ordinance Cod,a,N, <br /> Stantlards nttl$TATE anNor RDEM1.lawn CEM RepnbHnna.As tk vndenigned owner,operator,or ageN of tho propery touted at tlN ahwe ladilt <br /> Ah" <br /> address,l hereby avthodm the mbM <br /> any and allreuna and en"ronmen,l assessment Ivlbrmation to SAN JOAQUIN COUNTY ENVIRONMENTAL MALTR DEPARTMENT foe r It b ayslbbk sad ar the anew throe It <br /> proYMad to est or my rcprtuNaHve ^'T� <br /> cPPLICANTNAME C.Y/tT�1 1 ^1J{"Tt P1Fwsa PwNr SIGNATURE <br /> TITLE DRIVERS LICENSE# <br /> C7EOL6Ci14rT (MarocarAEal D1 <br /> Apptovad By wm A®aMit,E r111ba Ao®Y9 ratt,plated BY Dae. (l 9 <br /> 19-02-002 Apol 25,2003 --,t^ <br /> 61 l��s� Ilo- �� <br />