Laserfiche WebLink
San Joaquin County Environmental Health Department <br /> o GREEN FORM <br /> DATE0.2„(a • QS MASTER FILE RECORD INFORMATION "MFR" <br /> cuencn AREAS FOR Fun WE ON'v OWNER ID# /j/j� CASE# UNIT IV <br /> ✓`TOWNER FILE <br /> COWL ETE THE FOL L 0 WING P RO P E RTY OWNER INF MA7ION; CHECKIF OWNER CURRENTLYONFILEWITH EHD ❑ <br /> PROPERTY OWNER NAME z PHONE 2-QR`1 O — 0-7,f <br /> First MI Last <br /> BUSINESS NAME / yJA 1��f /� �,yf Mu�N 1� SRC SEC/TAx ID# <br /> Owner Home Address � ` • DRrvER'S LICENSE# <br /> city STATE CA 7 9 S S a <br /> Owner Mailing Address <br /> Mailing Address City / `LJ 3 / State Zip <br /> TYPE of OWNER <br /> CORPORATION❑ INDIWDUP_ PARTNERSHIP❑ FED AGENCY❑ OTHER❑ <br /> FACILITY FILE <br /> FACILITY ID# n�/ CROSS REF ID# AccouNr ID# fy/� INv# <br /> OMPLETETHEFOLLOWING NFORMA770111• !/V <br /> Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ No <br /> Is this an EXISTING Business LOCATION but a NEW TYPE of regulated Business? YES No ❑ <br /> BUSINESS/FACILITY/SIZE NAME ///J �•�' � Q <br /> SITE ADDRESS /0 �j)/�_- C.� -/�% ✓ C SUITE# BUSINESS PHONE , <br /> CITY STATE C- ZIP <br /> BOARD of SUPERVISOR DISTRICT LOCATION CODE KEY1 LK <br /> 2 <br /> Mailing Address WDIFFERENTfrom FadlityAddress Attention:or Care Of(optional) <br /> Mailing Address City _, A STATE �A ZIP CI' S��►70���� <br /> SIC CODE APN# )_0 9/_7O O Z COMMENT: �/��/ <br /> THIRD PARTY BILLING INFO: Complete if Billing Party is different from Property Owner or Facility Operator identified above. <br /> BUSINESS NAMEMailing Address <br /> ,(Ace <br /> `� /��� J / ` (v G` A fe s l Attention:orCare Of (optional) <br /> I /1 1' J d -43q-- Z <br /> ci�e,s f N�Mt�e-r L q�� Sri e F PHONE (Z O 9 ) 7 Z <br /> CITY S f p G Kyzi STATE C.Q ZIP �SZI? <br /> ccQu LADDRESS for fees and charges OWNER FACILITY/BUSINESS THIRD PARTY BILLING <br /> RIL1.1 NG ANTI VOMPI IANCE ACKNO LED-GM ENT: 1,the undersigned Applicant,certify that 1 am the Owner,Operator,or Authorized Agent of this Business,and I acknowledge that all PERMIT FEES, <br /> PENA[71ES,ENFORCEMENTCHARGES and/or HOURLY CHARGES associated with this operation will be billed to me at the address identified above as the ACCOM ADDRECC 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 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 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 Fi-,o— W, (a u S SIGNATURE <br /> TITLE !Y a • L°Gt Geo Io (S� DRIVER'S LICENSE# <br /> (PHOTOCOPY REOUiRED) p� p <br /> Approved By Date Accounting Office Processing Completed BY Date <br /> 29-02-002 April 25,2003 <br />