Laserfiche WebLink
San Joaquin County Environmental Health Deffrtment <br /> DATE MASTER FILE RECORD INFORMATION "MFR" GREEN FORM <br /> SHADED AREAS FOR EHD USE ONLY - :OYVNE(tlQ�1 CASE#. -- UNIT IV <br /> OWNER FILE <br /> COMPLETE THEFOLLOWING PROPERTY OWN ER INFORMATION; CHECxtF OWNER CURREArnroyFILEWrHEHD ❑ <br /> PROPERTY OWNER NAME <br /> PHONE 209 333-6800 <br /> First Ml Last <br /> BUSINESS NAME City of Lodi/ Northern CA Power Agency SOc SEcITAx ID# <br /> Owner Home Address 12745 N Thornton Road DRIVER'S UCENSE# <br /> City Lodi STATE C A ZIP 95242 <br /> Owner Mailing Address 12745 N Thornton Road <br /> Malting Address City Lodi State CA Zip 95242 <br /> CORPORATION❑ INDIVIDUAL❑ PARTNERSHIP❑ FED AGENCY❑ OTHER <br /> FACILITY FILE <br /> FACILITY Ip'# - `CROSS'Rer ID# ACCOUNT ID# - -INV# - - <br /> COMPLETE THEFOLLOW/NG BUSINESS/FACILITY/SITE INFORwTlo <br /> Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPT.? YES ❑ No (� <br /> Is this an EXISTING Business LOCATION but a NEW TYPE of regulated Business? YES)p NO ❑ <br /> BUSINESSIFACILiTYISrrE NAME Northern CA Power Agency <br /> SITE ADDRESS 12751 North Thornton Road SURE# BUSINESSPHONE <br /> CITY Lodi STATE CA zip 95242 <br /> BOAR DOFSUPERVISORDISTRJCT - LOOATIONCODE Kky1 -KEY2 - <br /> Mailing Address IfDIFFERENTfromFacilityAefdress Attention:or Care Of(optional) <br /> Mailing Address City STATE ZIP <br /> LfLDE APN#. COMMENT: <br /> TKIRD PARTY BILLING INFO: Complete ifBilling Party is different from Property Owner or Facility Operator identilledabove. <br /> BUSINESS NAME Attention:orCare Of(opt/onal) <br /> Melling Address PHONE <br /> CITY STATE ZIP <br /> AccouNTADORE53 for fees and Charges OWNER FACILITYIBUSINESS THIRD PARTY BILLING <br /> BILLING AND COMPLIANCE ACKNOWLEDGMENT: [,the undersigned Applicant,certify that I am the Owner,Operator,or Authorized Agent of this Business,and I acknowledge that all PERMIT FEES, <br /> PENAL77ES,ENFORCEMEAfCHARGES and/or HOURLFCHARGES associated with this operation will be billed to me at the address identified above as the ACCOUNTAUDRESS 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 ail applicable SAN JOAQUDV COuNry Ordinance Codes and/or <br /> Standards and STATE andlor FEDERAL Laws and Regulations. 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 DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my representative. <br /> PLEASE PRINT <br /> APPLICANT NAME Mary Halpin SIGNATURE /tfAAAA <br /> /tjF�A� <br /> TITLE DRIVER'S LICENSE# <br /> Permit Coordinator 0HOTOCOPYREQUIRED) 4719 68 <br /> Approved By Date Accounting Office Processing Completed By pate <br /> 29-02 10/12/07 MASTER FILE RECORD-GREED' <br />