Laserfiche WebLink
San Aquin County Environmental Health Atiartment <br /> GREEN FORM <br /> DATE ` MASTER FILE RECORD INFORMATION ITMFR" <br /> Gun IIsFnnX OWNERID# o�Dooa�.� CASE At UNIT IV <br /> OWNER FILE <br /> LRECN IF OWNER CORRFN2YONFILEWITN EHD ❑ <br /> COMPLETE rHE FOLLoc w PROPERTY OWNER IHFORAfarrOH: p �J <br /> PROPERTY OWNER NAME L 4�/e S (� �p� PHONE <br /> First MI Last ✓ •/ <br /> BUSINESS NAME A/A— SOC SEC/TA%ID# <br /> Owner Home Address 'V/T !.v � 1 ,r/prs DRrveR's LlcExsE# <br /> City `— !, V Imo. F'1�- STA /� ZIP �j.. <br /> Owner Mailing Address e. •]"� '/ <br /> Mailing Address City State ZIP <br /> TVnr ncrlw <br /> CORPORATION❑ INDMWAL PARTNERSHIP❑ FED AGENCY El OTHER El <br /> FACILITY FILE <br /> F CILITY ID# lno�'l ll rp CROSS REF ID At ACCOUNT ID At A.(1�_2j C/ INV# <br /> Is this a NEW Business LOCATITON not previously regulated by the ENWRONMENTAL HEALTH DEPARTMENT? <br /> YES ❑ No <br /> Is this an EMSTING Business LOCATION but a NEW TYPE of regulated Business? YES ❑ No <br /> BUSINESS/FAatm/SIre NAME �f \ti S <br /> SIZE ADDRESS �� S # BUSINESS PHON 0�1 <br /> CITY �CtL�- STAT�� ZIP <br /> BDAPDOF SUPERaI RDLSf a LOCATION CODE KEYS REYZ <br /> Mailing Address ifDIFFERENrfrom Faril dress Attention:or Care Of(opinosia/J <br /> Mailing Address City STATE Zip <br /> SIC CODE =1 <br /> APN# COMMEM: <br /> THIRD PARTY BILLING INFO: Comp/lute if Billing Party is different from Property Owner or Facility Operator identified above. <br /> BUSINESS NAME I\ ,�1 _1 Attention:or Care Of (apbonaQ <br /> Mailing Address ' 300 'T5dJ1 `C�—H-ry�+ PHONE <br /> cm � J 1 L�.y STA Z1P5 / <br /> aQQ2Lmq ga9EW for fees and charges OWNER FACILITY/BUSINESS THIRD PARTY BILLING <br /> I •• r awR ACRNRR snr.MrNr; I,the undersigned Applicant,certify that lam lire IT-11,Operant,or Authorized Agent of this eu siRuss, PER WIT FEES, <br /> PE.N'ALTIF.S,E.vr'ORCEMENTCaARGEs and/or HOL'RLYCHARGES associated with this Operation will be billed to me at the address Identified above as the 4ccoo!i-jamRF.c.0 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 fceilitylsite address,I 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 an,or my representative. PLEASE PRINT <br /> APPLICANT NAMED01.,j SIGNATURE <br /> TITLE DRIVER'S LICENSE# <br /> (PHOTOCOPY REOUIREDI <br /> Approved By Date Accounting Office Processing Completed BY Date C 7 <br /> 29-02-002 April <br /> 225,22/003 <br /> V r' �� <br />