Laserfiche WebLink
San Joaqul County Environmental Health Department <br /> DATE if/ MASTER FILE RECORD IwoRMATioN"MFR" GREEN FORMA <br /> / 2 SITE MITIGATION&LOP <br /> sNM pe"rme"Ow!WILY owtisotwx CAtitlr Sro0 S3 UNIT 1V <br /> ommt Fun sC6A rLETETHEFoucjwom PROPERTY OWNER hVPV W r10N.' Cmwz rjF OVWHER GwAxwmypN►af PwM EHD <br /> pwowERTYDentewNwt ,� O Q Q='� <br /> fk.! aN! Las( Pltane t+ltN�sre <br /> etsab.Aotwtwre <br /> euebeneNAre y�`t�s?'i+1 �f �"4 4!/ G � <br /> OvvnK}iatne Addwsa <br /> oft70 erAT! zIP <br /> Owner MsIwIB Addrrns <br /> 6&r17- feO Ae,0sr. <br /> CowwaaTnN� INetvaawAL❑ PlutraetD►sNtw❑ FEoAOENOY❑ Otlieit❑ <br /> rise IiAtsssastobt_eNvifl�thTRN+rJ►L As T_ _VOLIJN'fARY M&MUt•_.%%"m emu" HW ftnUme offifU taJ►M"_LOP._ <br /> 3g�3 D �� p �DTiO <br /> FAcEPA_ <br /> anYtDA INYN AcoouNTID PR ss Ass LawgAOSNOY'EH <br /> ACILIT1fFN.e Caank-fftHEFouow"BUSINESS IFACILITY ISITE AwOAK47w <br /> 1s ibis a NlEw&Mnm LOCATION nc#pnviou*reguNded by tlta ENvacNhtENTAL HBALTH DEPARTMENT? Yes ❑ No <br /> 19 this an E=Tm Bushm LOCATION buts NEW TYPE ofrtlgriolated Swinsss? YEs ❑ NO <br /> 6tranewaffAciurfiBneNAas Q► V q Q <br /> sunty P <br /> ooto <br /> Ciro rA ZIP <br /> 7— a c <br /> DOAtoorBuwHtvldORDtaTwtoT LoosmiiD00! Kof Ka12 <br /> f"ItInp Addreta ef01Fa WWffrlrcrn Fiol Aa4dtsae Aiteevilm:arCsre Of(OpAbW <br /> Mali ft Addt.a City STATR Ztw <br /> BICOOott AIN, _ /� S COwtelrr <br /> TMIto FAMY BILLING INFO: Coon Mfee ifBMbV Party is different from Pro Oiwner orFWI&O rvA*r k(efti od above. <br /> BusxaasiNAtn /� ✓l / Atterrilon:asrCarss Of/epffanO <br /> mawaaAddtwss �r ,fPtion11 / Cy <br /> A!73 7 I/ Qr nrs! <br /> C," l raa�,�s ra =� <br /> forfessand ahorgas OWNER FACILgyfflinP1au THIROPARTY BRLNG <br /> . t,blas pnderai=ned Applie�lpt,crrtify 1►at I em the Drwtr,Operaror,a'AerArrhrf A�tnfv[thlt E�ewr.Itad Iae�nrtedee EE��aq l'Itia►U7'F1gY, <br /> P&UL7rrS,4ENFORCa"UNA7CNwrGet amllor HMPALY iumn aerocE.led vdtk ills eperstWn will be Mued join at eke sddrew IdewtflEed above an tiw Iar thae Wtt-1 SNO oedifj tYd <br /> all Informelion pr"kUd on thin application is trove and eorreM and that all retwined attivh@s will bt pudlell d In wceordotxe wkb an appiicable SAN JOAQNIit COMM Ordinance Coda awjkr <br /> StnadoWs sad STATE and/or FabtAAL t.nws aad Rrjatatimu.As rhe undersigned Owner,apfralor,or agent of Tho praptrty ioeAted at the above foeRityhile addmh l hereby aathedw the rdame of <br /> any and all ruaNs nad euvireamemai 4%ussment infbrmation to SAN JOAQUIN COUNTY ENVTR0N14EN'rAL HEALTH DEPARTMENT n soon as it h smllaWe and at the came thin It Is <br /> prmided to ak or my repreuntadve. <br /> APPLICANT NAME MCAse PRINT) <br /> ��1� <br /> TITLETAX ID 0 <br /> .. <br /> ApprossadiluOlio Aaeeun Olnae Waeese OeM y <br /> BM "DUMP DATR PAYMNtrWisti RecslwrB CHaO+t1f Racmvso Y � �,-W`. <br /> ��; "" d 1rz9--0 1 Z <br />