Laserfiche WebLink
San Jo•in County Environmental Health Department <br /> DATE MASTER FILE RECORD INFORMATION "MFR" GREEN FORM <br /> SHAG ARE"FOR EHD USEONLY <br /> OM,NERID# UNIT IV <br /> hT CABER <br /> 11 V C FIL! <br /> Colli rHEFOLLOwrNGPROPERTY OWNER/NFoRMArm.* CHEDKIF OWNER Cu iffmMy"MENTM END <br /> PROPERTY OWNER NAME � �Lv +f w <br /> —t PHONE 4CI.— Si1 —x1-11 <br /> First M, <br /> Lest <br /> BUSINESS NAME <br /> V` /"N-7W-o�l�S 3009Ec/TAx ID# <br /> Oa nsr Horne Address <br /> Scar <br /> DRIVER'S LICENSE# <br /> City (y� <br /> O rY`Q O STATE I LP �.�,�7 <br /> Owner Malling Addre m \ <br /> F>—S A <br /> Meiling Address City <br /> aled. 21p <br /> CORPORATION INDIVIDUAL❑ PARTNERSHIP❑ <br /> FED AGENCY❑ on1ER❑ <br /> _ FACILITY FILE <br /> FACILITY ID# CROSS REF ID It <br /> NvL! ACCOUNT ID# (NVO <br /> C019fP1-E7FrHEF0L1OW1NWGJBJUSINESS/FACILITY/SITE/NFORMA770N.• <br /> Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPT,? YES ❑ NoA <br /> Is this an EXISTING Business LOCATION belt a NEW TYPE of regulated Business? <br /> YE, ❑ No <br /> BUSINESSIFACILTTY/SITE NAME <br /> K <br /> Sf1EADORE89 .7 3 / p <br /> J p SuOE# BUSINESS PHONE <br /> CITY <br /> Cl A? II/ r s `f` STATE zip 3'7 <br /> BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEY1 <br /> KEY2 <br /> Melling Address HO/FFERENr#cwr F..WAddress <br /> r <br /> _I L,f 1L'L"1` AtLMIBsn:or Cera Of(opNpra// r <br /> Melling Address City <br /> J 1r,` ,.�/I �• �4r{�L 4p <br /> `"' 2l !J /'(fid STATE zip <br /> N <br /> SICCODE APIt COMMENT: <br /> THIRD PARTY BILLING INFO: Complete ifBilling Party is different from Property Owner or Facility Operator identirledabove. <br /> BUSINESS NAME <br /> Attention:crCare of(Optlona/J <br /> Meiling Address <br /> PHONE <br /> CITY <br /> STATE zip <br /> AGQQm¢Aoag„gE for fees and charges OWNER FACILITY/BUSINESS <br /> THIRD PARTY BILLING <br /> BILLINGPEiVIL rim. <br /> AND COMPLIANCE AC Go,..EDGMENT: I,the undersigned Applicant,certify that I am the Aen¢g OPera/Or,or An//mrized Agent of this Busi......d I acknowledge that all PERJAT FEES, <br /> P£N.ItT/eS,ENFORCEM£NT CHARGES and/or ROUN YCIIARGEf associated with this operation will be billed to me At the address identified above as the ACCOUNTADDMs for this Site. 1 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 ofthe property located at the above facility/site address,1 h <br /> any and all results and environmental assessment information to SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTM T as soon es it is avaiF le and athori a the <br /> fimerelease <br /> is <br /> provided to me or my representative. <br /> APPLICANTNAME PLEASEPRINT <br /> SIGNATURE <br /> TITLE <br /> Po.. Zc"r— C` 12"t" LS DRIVER'S LICENSER <br /> —I IL± PHO TOCOPYREOUIRED <br /> 29-02 10/12/ I <br /> A02 10/12/07 Data Z �S Accounting olnee Prooeaelag C—PhAday <br /> Oefe S <br /> MASTER FILE RECORD-GREEN <br />