Laserfiche WebLink
T"TO LEGAL Fax: 717-592-4022 Dec 22 2004 16: 02 P. 02 <br /> o• C 17 2004 17=25 FR EAR' ECH 4082322801 TO 91-M8526133 P_02,02 <br /> Saul Joaqu County Environmental Health DepWnent <br /> GREEN FORM <br /> DAA � ���`� MASTER FILE RECORD INFORMATION "MM""' '11 <br /> ea+.rsn avca5 r;t>•FJJI'f tits fhu• V✓ D��/Lryr- I� I UNI ■ l■ <br /> V <br /> OWNER FILE <br /> compuTerMFR9 : <br /> LLOWI &PROPERTY OWNER INAORM�170NC►/EGr,a owNEErCvx.Eyrt�rmvRtcl�rjrxTprr'ENu <br /> P"PERTY OWNER NATE O 6 LEN �ST�p PHONE -20r"/il�f0y <br /> ftnr �f/ Last <br /> B4JSIt+r�N.►+t .YGJ soc seB I Tnit <br /> P2�N C UJB z3-o 031 <br /> Owner Home AAddter5 <br /> city /G®�GN�/r G�/s ///���� <br /> ���J�V` ST.TE�� Z. <br /> am"m Marling Address <br /> aR7rtrp dm--n City Staa �P <br /> CtxtvorrAT[ON)a .. A mraoum.D PjurrWAa-0 IV❑ FED AeENCY D OTNlA❑ <br /> PACILITIf FILIE <br /> F►cunt ID Jr !/?I�f7 f� I Otmat(�r+f TD dr <br /> ACCOWT M s Irrv. <br /> HPL WIN N <br /> Is this a New eusilntaa LOCATION not previously regulated by the ErlvutoNMPrfrAL HEALTH DEPAR.THEM? YES No ❑ <br /> Is this an EXMT114G Business Lac 'nom but a NEw TYPE of reguI ted BIJSinessl Yes Cl No Cl <br /> ti SM AODP&W 19150 w�ST � �Olt7r' S'1^. Surma <br /> ST-06.I4LTUP RrATE C4 3- D <br /> a <br /> Halling Address 1f0ZFFFWEWhom AEftntlon,or Care Of(opOorld) <br /> Mailing Addrtei City STant - .. <br /> THIRD PAKYY kill-LING INFO-. Complete if Billing Party is diiferr'nt from Property Owner arracility Operator ideriMed above. <br /> steel" rAY- .. At♦mntlon:of Cam (opho 0 <br /> wiling Address PHO E <br /> Cr" scar 2a <br /> AQ0&L9s for fees and Charges OWNER FACILITYMUSMESS THIRo PARTY BILLING <br /> jtt�t lAf..wn ro•+vrr.�y(F nrrcHewr rncdrrnr; L the underyl;ard Applieset,certify what 1 Am due Arva.Y,flparefor,orAillhorileJ Arr4rar(his Rosiataa,end 1 aekoo-kdse thm all PFRMTFE" <br /> Pd*+1+ G�aadh.r MOM..YOlARr,F.t'asiocimed—rh ibis oprrafi—r ill Ise billed to me at lh addrew identiflol oho-e at rhe drYurwlAau..mnM re,this lira 1 also certify cher <br /> all informiaon pro-idcd on this nppticari..-to-k—AnJ correct:and that all rtgulAwd nada—mill bo performtd in accordance with all appl cable SAN JOaQUIN CounTv O ntiaance Caries and/or <br /> SonJ�rdy Dad STAI£sadlor FCDEr1�l La+•s and Rgvtaar��. A�the undersigned owner,opermor,or atmr yr ncc l—perly IOCltcd■t she ata-r facility/Tire address;1 hereby ituMonar me release of <br /> any—d on n—P.rnJ mrironmenul aneurne t taferm►tion Ip SAN.tp,%Ql11N COUNTY ENvIRONMENTAI•JIL,,LLTH DEPARTME a Soon a a1.61 as ar the snmc'nmo it i, <br /> proWJal of arc..r a'7.tproUl+rn•e. <br /> APPLICANT NAME � f � /KaRl�►r SICNATVRE <br /> 71J. (swotram oE0 tcaFn <br /> Apprsnrad sy Oak Aowutr�tsq OYFr�Rocesaln0 Cer..rplrsd eY paatr I•. `��� <br /> 19.02.001 npril 23,300) � . <br /> *� TOTAL PAGE,02 *� <br />