Laserfiche WebLink
San . (buln County. Environmental Health L*rtment <br /> DATE MASTER FILE RECORD INFORMATION "MFR" GREEN FORM <br /> INAQ9DAR9AAEQR EHDVSE ONLY OWNER ID# —� CASE# UNIT IV <br /> OWNER FILE <br /> COMPLETE THEFOLLOW/NGPROPERTY OWNER/NFORMATTON.' CHECK/F OWNER CLWRENTs r CNFz1CWTN EHD <br /> PROPERWOVMERNAME PHONE <br /> First MI Last <br /> SUSINEss NAME I • SOCSECITAXID# <br /> Owner Home Address; I Jr CL r <br /> S l / 21v e— DflrvER'S LICENSE# <br /> City ✓UJ4r <br /> C CFee STATE Ch ZIP G 5/_ <br /> 4> <br /> Owma,Mailing Add.. + :S tZ A-I t_AN RIVL-- 1 ` 1 llLU <br /> Mailing Addresa City v.l,,�t_2r - P <br /> $Iafe >, q slay <br /> CORPORATION❑ INDIVIDUAL❑ PARTNERSHIP❑ FEDAGENCY❑ OTMFR❑ <br /> FACILITY FILE <br /> FACILITY IDM CROSS REF ID# ACCOUNT IO# INV# <br /> COMPLETE THEFOLLOW(NG BUSINESS/FACILITY/SITE/NFORMA770N.7 <br /> Is this a NEW Business LOCATION not Previously regulated by the ENVIRONMENTAL HEALTH DEPT.? YES ❑ No 2� <br /> Is this an EXISTING Business LOCATION but NEW TYPE of regulated Business? YES El No El <br /> BUSINEssIFACILmISITE NAME 1=0 Rpl�l'.IZ UMOoNot— 1 'ULWC t—e ArvT NO. Q <br /> SITE ADDRESS G (Ao� t I J1. .JrKGL <br /> OC! rT� $URE# BVSINES9 PHONE <br /> CITY <br /> STATEC_, ZIP /Z f3 oI f <br /> SOARDOFSUPERVISORDISTRICT LOCATION CODE KEY1 NEY2 �t J `Y <br /> Mallin Address NO/FFERENTfrom Faci/ltyAddrass Attention:oT Care Of(opbone// <br /> Mailing Address City <br /> STATE Lv <br /> SICCODE APN# COMMENT: <br /> THIRD PARTY BILLING INFO, Complete ifBilling Party is different from Property Owner or Facility Operator identified above. <br /> BUsINEss NAME Affengom erCare Of(opf/orlslf <br /> 5 G(�`EC_ COI\ Vt'Ytl� g p LIYW�IC'��. <br /> Melling Addrase '3�t--i ICi� OI`C �� {I�'O4�'c/}C�MO/a—�/� <br /> CITY �(,CI ` I� —L ✓l.f[ TV STATE.yS ZR s SlL/ EV <br /> A�u��v`O forfleasan(d�chWarges OWNER FACILITY/BUSINESS l-I"JTHIRD PARTY BILLING <br /> BILLING AND COMPLIANCE A OWLS E : 1,the undersigned Applicant,certify that l am the(huov.01wamr,or Authonce✓Agem,of this Businoac,and f acknowledge that all PERA/a'FE&, <br /> PEN.eLTTES ENFOR(ENPW'CHAR Ee and/or H()URi.r CHAROEI'.ss.d.ted with this operation will be billed tome at the address identified above as the A[046YrAnbRF_cS for this site. f also cedify that <br /> All information provided on this application u true and correct;and that all regulated acdvides will be performed In accordance with all applicable SAN JOAQUIN COOYry Ordinance Cades and/or <br /> Standards and STATE and/or FEDERAL Laws and Regulndons. As the undersigned owner,operatuq or agent of the property located at the above facility/site address,)hereby Authorize the release of <br /> any and all resales and environmental asseasmuU informed..to SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It is available end at the same lime it is <br /> provided to me or my repri,som.ive. <br /> APPLICANTNAME 1'h WI21� �, I�KleC PLEASEPRINT SIGNATURE <br /> TITLE Str>Jt Oz Gt"b(A CGt)T- DRIVER'S LICENSE# <br /> J (PHOTOCOPY REQUIRED) <br /> Ad Date AcnounlMp Dance Procosslrg Com label BY Da <br /> 29-0022 1 100/122//0] ta <br /> MASTER FILO RECORD-GREEN <br />