Laserfiche WebLink
San Joaquin County Environmental Health uepartment <br /> GREEN FORM <br /> DATE �J-�$-I� MASTER FILE RECORD INFORMATION "MFR" <br /> ` � UNIT IV <br /> IICF D-V <br /> CHAnFD•RFAG FnR r OWNER ID# 9 c� CASE# Coco&,a c>.? / <br /> OYYNER FILE <br /> COMPLETE THE FOLLOWING PROPERTY OWNER MFORMA7TON; CHEcKrF OWNER CURREV TL YON FILE WITH EHD <br /> PROPERTY OWNER NAME PHONE L I V —3_IS—7-000 <br /> First M1 Last <br /> BUsINEss NAME 1SOC SEC/TAx ID# <br /> a tro En2r CoraCa_�-i0h VIA- ^lof Rs •�r,�J� <br /> Owner Home Address -011c <br /> 1 r DRIVER'S LICENSE# N A N'er+r Ountr QA y <br /> C {{II{{ h e Vel�Q o W <br /> C" Sol-^ /4��h 1 0 STATE TX ZIP T b 7-'1 - <br /> Owner Mailing Address f O 1" 0)( 6 9 6 0 D 0 /� <br /> Mailing Address City SOLA A-,L7'pvtIp V State T- ZIP b2-6 000 <br /> TYPF nF nWNFR,a4 <br /> CORPORATION u INDIVIDUAL❑ PARTNERSHIP❑ FED AGENCY❑ OTHER❑ <br /> FACILITY FILE <br /> FACILITY ID# O Q (� CRoss REF ID# �{?o 00J�-7 l A�ct�N &t, 60gyV0 INV# <br /> OMPLETETHEFOLLOWING NJFORMI AA7TON, <br /> Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ No Rf <br /> Is this an EXISTING Business LOCATION but a NEW TYPE of regul�at(/ed Business? 1y� YES ❑ No @I <br /> BUSINESS/FAcaxry/SITENAME vO em ►.Yt Gr 1�'�OIn I V�S YJt 1 <br /> SITE ADDRESS 3 5 n S Npv t V SUITE# BUSINESS PHONE <br /> t S/a- n x/10 <br /> CITY (�0 C��� STATE CA ZIP 157-v-3 <br /> BOARD OF SUPERVISOR DIsnucT LOCATION CODE O t KEY1 KEYZ <br /> Mailing Address ifDIFFF Tfrnm Faai/iftyAddress Attetltion:or Care Of(optional)PN <br /> 90 92,% a to AVtnul�ntd <br /> t- RIC &(tAgf5 R ;oAa( µ5E M <br /> Mailing Address City �r„r(�, STATE„A ZIP <br /> HSIC CODE APN# Q-U COMMENT: <br /> TARTY BILLING INFO: Complete if Billing Party is different from Property Owner or Facility Operator identified above. <br /> Ax4SS <br /> J�NAAME Attent ^f /',a.. <br /> Mailing Address_ /1/7 <br /> PHor(,hI -5 97—220 <br /> t CITY / •V(/lX�1S�'U � <br /> STATE/1 /t ZIP <br /> Acr mmn An R.F-Tg for fees and charges OWNER FACILITY/BUSINESS THIRD PARTY BILLING <br /> 1111.1 INC.AND('ONIPI.14 N('P 4CKNO\1'I.T II(-"" : 1,the undersigned Applicant,certify that t am the Owner,Operator,or Authorized Agent of this Business,and 1 acknowledge that all PERAUT FEES', <br /> PEN.1L77ES,I..,.CEA7E"W'CI"[. EC and/or 1)(1URLYCIL4RG'ES associated with this operation will be billed to me at the address identified above as the 4rTnrmr4nnaFCc fur this site. I also certify that <br /> all information provided on this application is true and correct:and that all regulated activities Mill be performed in accordance>vith all applicable SAN JOAQUIN COUNTY Ordinance Codes and/or <br /> Standards and STATE and/or FEDERAL Laws and Regulations. As the undersigned oe'ner,operator,or agent of the property located at the above facility/site address,l hereby authori7e the release of <br /> any and all results and environmental assessment information to SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTI4 DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my representative ���I-/ `--� <br /> APPLICANT NAME PLEASE PRINT SIGNATURE J_ <br /> TITLE M ( / 1 DRIVER'S LICENSE# G s y o 0q <br /> Task ( WLA2 J� F ko 0 1 s r (PHOTOCOPY REQUIRED) <br /> ILApproved By Date Accounting Office Processing CompletedBy �..�' Date <br /> 29-02-002 .April 25,2003 i L <br />