Laserfiche WebLink
• • RECENE <br /> lvUV 2 0 2009 <br /> San Joaquin County Environmental Health DepartmentwIA4. 4 <br /> ENT HEALTH <br /> DATE I I ZE' °5 MASTER FILE RECORD INFORMATION "MFR" 1?E �" `' E' <br /> .....ar.�....pun «n.r OWNER to# oobt Er CASE UNIT IV <br /> W uVO-WNNERFue <br /> CoAi7NEFOLLOHGNGPROPERTY WN NiORMATfOM• CNmra<OWNER CURRENTEIMAnrwnNEHD <br /> PIrIRaRTY OWNER NWAE V/i' dA (— <br /> r.AAY1/'1 T PMDNE N <br /> P First MI Last nANc Cflt W�l( QT I�� /F0(1,vH a0, T�l�i}CO S(XSK/TARro# ^ <br /> Ownerliarne Address S I D 1. r I ms f Sep DRNER's L! E# <br /> `A', TSCA SrA,EC� z. r ;sS3 C� <br /> Oanter,Mailing Address <br /> Mailing;Address City Stare Bp <br /> hoE nr nrurvona <br /> CORrauTlort❑ [NOtVmUaL❑ PARrrexsHs❑ <br /> hm AGFRCY❑ Onca❑ <br /> Al <br /> FACILITY FILE c <br /> II <br /> FACILftr IDat fk Caoss REF ID# ACCOUWID# X10035691, IW* '_V <br /> rl <br /> Is this a NEW Business LOCATION not P111111-Sly regulated by the ENVIRONMENTAL HEALTH DEPARTMEIM vER ❑ No ❑ <br /> Is Otis an EXISTING Business LoGTIoN but a NEW TYK of regulated Business? ym ❑ No ❑ r� <br /> Business/FAmTrr/SM NMI C V0 A T) <br /> SRE AtAsggs 3E5`3 C \\C.S T SLNE# BUSn2SSPHONE <br /> cityV <br /> `cScn`.sa N51TATI rm <br /> rAdd� <br /> DEnURHinz <br /> T REA'rfmr,Fad/RyAdYfefs Attention:or Care Of lcEkFr+/IO <br /> STAI! Zy PN <br /> # CDMNENT: <br /> THIRD PARTY BILLING INFO. COMP/ete/f Billing PartY Isd/{fefentfro/n Property Owner orFadlity Operator Ndenl'/W above. , <br /> BtaRNss NAM, l ."���1�.y1 ��V\f'�Ia AtteMlan:n-eare of 0=1 t 1 �C�� <br /> Mailing Addmss <br /> \012 N\a�ac,r�3� sem, w7 f Cvaw o. ��q13 ""'N S� 3H� X333 <br /> CITY <br /> STATE m <br /> A`COUNXA,a^^ece for fees and diarges OWNER FACILITYIBUSINFSS <br /> (THIRD PARTY BIW <br /> 1,Me undersigned Apptinn4 certify that I am IM Omer,Opermor,or AYMortredA nt of Mta Bod x� VLLimmal <br /> PENALTIES,ENFO S ENTCHAAGE nrlf,End .` Wife that all PERM?FEES, <br /> and/or NOveo Y CmaR"r aaouvted aelth Mia openiw w01 be MINI to meatMeaddress ldentidedidmo,.the ArmpurAnn.vc,for Mh alta provided Iaho certify Mvi <br /> Standards and Stere and/or PEDEallie dotaoanon vided on Mu vpplkation la true and rorrect;and ttit aH regiactlritia wH16e performed N acrmdaatt with all applkabk SAN JOAOOM COIIMI'ONimana Coda and/or <br /> IGL lawn and Regdafiom. ti Me undengoed owner,operator,or agent of er,property healed at the above f.ilityhim Wants,l hereby a di orae the rete.,of <br /> any and All results and envirmmennl asessment udornutr'rm M SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTIEPARTMENT.eoon.it h availabk and at Me same tines ith <br /> nu <br /> pr.Aded to or my representaive. <br /> APPLICANT NAME \ �'�pg� <br /> W�� T SIGNATURE <br /> TITLE ` DRIVER'S LICENSE At <br /> W��.OFZsi Case 4RtT., s \1.L frxoromrr REQUIREOI <br /> AM oanot By <br /> WOe Accounting Office <br /> psora Dao 0 <br /> 29-02-002 Apri125,2003 > � <br />