Laserfiche WebLink
It <br /> San Joa uin County )lic Health Services Environmentf 'ealth Division <br /> I <br /> � GREEN FORM <br /> DATE MASTER FILE RECORD INFORMATION "MFR" <br /> ru OWNER ID# v�/D � CASE# UNIT IV <br /> OWNER FILE q <br /> CHEGKIF OWNER CURRENILYON FILEWITH EHD <br /> COMPLETE THE FOLLOWING PROPERTY OW N ER INFORMATION: <br /> PHONE <br /> Food MI last <br /> BUSMF55 FUME SOC SEC/Tu ID# <br /> Owner Home Address 6 D� til4siezi, M DRIVER'S LICENSE# <br /> 0.0, e e <br /> city STATE IIP <br /> owns Maimq Md. <br /> Mailing Address City g9isTvV11 <br /> State Zi <br /> rvoc nc nwxcowrn <br /> rnomo.nnx ruln,y.,.��n(/,��e, Do.71Noecxro❑ FFn Ar Nry❑ nTHco Cl <br /> Ferxmrn to Q/..3YaIs rnne<Oee inn erm„xc rn ie INV# `il <br /> Is this a Nm Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DIVISION 7 YES ❑ No 54 <br /> Is this an EXISTING Business LOCATION but a Nm TYPE of regulated Business 4 YES ❑ No ❑ <br /> BUSINESS/FACIIm/SITE NAME <br /> C-VAF\jItatA Seczvc P S� kip ZU\383 <br /> SITE ADDRESS SUITE# BUSINESS PHONE <br /> n(p,o SknEeA <br /> CITYSTATE IIP <br /> 1Rp.Ly CAA gS3llo <br /> IIBOARDOFSuKRvISORDlsTiU f I I LOCATION CODE I I KEY1 I KEY2 <br /> Mailing Adr,ss fDJFFFRENTFrum Faci/i Address \:/'O.L P1b�L�c'I�� KP`�'ty Attention Cam Of(option/) <br /> 6c+s f Il ( <br /> Mailing Address City <br /> w Qn'LG � STATE P <br /> SIC CODE APN# COMMENT: + <br /> THIRD PARTY BILLING INFO; Complete if Billing Party is different from Property Owner or Facility Operator identified above. <br /> BUSINESS NAME / / / Attention:orCare Of (optional) <br /> Mailing Addressr • ' ! PHONE nr fJY(' J <br /> ^ // 0%�\� <br /> CITY STATE IIP <br /> ArmuAnnocee for fees and charges(_ OWNER FACILITY/BUSINESS THIRD PARTY BILLING <br /> 1,the undersigned Applicant,certify that I am the Owner,Operator,or Audmrired Agent of this Business,and 1 acknowledge[hat all PERMIT FEES, <br /> PE.VALTIEs,EAFORCEMCry CHARGES and/or I/OURHY CHARGES associated with this operation will be billed tome at the address identified above as the ArrQ1rATADORFeV for this site. 1 also certify that all <br /> 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 Reguladom. 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 DIVISION as soon as it is available and at the same time it is provided to <br /> me or my representative. <br /> ^'y j /�/y PLEASE PRIM <br /> APPLICANT NAME IL - <br /> LI lrf re- SIGNATURE <br /> ////llll I fMY Yr <br /> TALEn(f.� `Q �s a!� v.pj' t//ilrt�' / J/ y / lI DRIVER'S LICENSE# ] <br /> Y b c/•I/Ls'uC ' G'G�m LK CSS.L�(lf'�.Jr < 1'Cl r•�) fPHOTOCOPYREOUIREDI <br /> Approved By Date Accounting Office Processing Completed By Date t? �) <br />