Laserfiche WebLink
i <br /> f <br /> San Jc_,.�uin County Environmental Health Dep,,.tment <br /> s GR-7-N FORM <br /> DATE , t(-1 0 MASTER FILE RECORD INFORMATION '"MFR" <br /> Cuencn•ncec Fne FNn 119F OWNER ID# CASE#(lu+v <br /> __ 77 - I V <br /> 1 <br /> OWNER FILE \may <br /> COMPLETE TME FOLLOWINGPROPERTI OWNER INFORMATION; CHECKm OWNER CORRENnYONFrLEwrTN EHD <br /> PROPERTY OWNER NAME PHONE 907 V6�_u ��LL– <br /> (� First Ml Last <br /> BusINEss NAME Oen <br /> A p Soc SEC/TAx ID# <br /> Owner Home Address `✓` V t) _I/U DRIVER'S LICENSE# <br /> Crty _ 0 GC STATEcA l s�2-03 <br /> Owner Mailing Address C, ` DO{� <� <br /> Mailing Address City b 1/ State / Zip <br /> TVOF nF nwNFnWiG l <br /> CORPORATION❑ INDIVIDUALS PARTNERSHIP❑ FED AGENCY❑ OTHER❑ <br /> FACILITY FILE_ <br /> a_ .s.._ LACCOUNT ID#— INv# — <br /> p <br /> FACILITY ID# CROSS REF ID# ,r}��O' Cj <br /> MPL E LO N l'SUE LYW_RffAZx0N.- <br /> Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ No ❑ <br /> Is this an ExisrING Business LOCATION but a NEW TYPE of regulated Business? YES El No 1:1BUSDVESS/FACLITY/SrrE NAME y.� LL- <br /> SITE ADDRESS IJ at(�v S _ SUITE# BusiNEss PHONE <br /> clrr C��.I�,^ STATE ZIP <br /> BOARD OF SUPERVISOR DISTRICT LOCATION CODE (, `, (KEY1 KEY2 _I <br /> i <br /> Mailing Address YDIFFERENTfrom FadlilyAddium Attention:or Care Of(optional) <br /> Mailing Address City STATE ZIP <br /> SIC CODE I APN# 1L COMMENT: <br /> THIRD PARTY 13ILLING INFO: Completed Billing Party is different from Property Owner or Facility Operator identified above. <br /> BUSINESS NAME Attention:orCare Of (optional) <br /> V�✓1 Le ►�U�rGh �wfiA <br /> Malting Address /) 7 V 1ii�(�t! L I ( <br /> PHONE x M / <br /> CITY ( STATE ZIP/07 <br /> for fees and charges OWNER FACILITY/BUSINESS THIRD PARTY BILLING <br /> �■.o.�wMlr - sem, _ _ _ F.wr�nwemFs�.mva�nr.,..�.nm.,�..wr.�.s._ <br /> RULING,AND COWT a NCR ACr Off FT)GAfENT: 1,the undersigned Applicant,certify that I am the Owner,Operator,or Authorized Agent of this Business,and I acknowledge that an PERwT FW, <br /> PENALTTES,ENFORCEMENT CHARGES and/or HouELYCHARGEs associated with this operation will be billed to me at the address identified above as the ACroUNrAnDRFtT for this site. I also certify that <br /> all 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,I hereby authorize the release of <br /> any and all results and environmental assessment information to SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soontim it is available and at the same time it is <br /> provided to me or my representative. <br /> APPLICANT NAME ►Jr t M�PLEA ?INT SIGNATURE <br /> TITLE J� ! DRIVER'S LICENSE# <br /> + GI (PHOTocoPY REQUIRED) <br /> App—,ed BY Data Accounting Office Processing Completed By r Date Q. L(� <br /> 29-02-002 April 25,2003 <br />