Laserfiche WebLink
ti <br /> r San Je luin County Environmental Health partment <br /> GREENFORM <br /> DATE MASTER FILE RECORD INFORMATION "MFR" <br /> SHADED AREAS FOR EHD USE ONLY NER ID# OD 6 3 UNIT I V <br /> O <br /> 111 <br /> OWNER FILE <br /> COMPLETE THEFOLLOWINGPROPERTY OWNER INFORMATION: CHFCKtF OWNER CURR£NTLYONFlLEtNJTN EHD <br /> PROPERTY OWNER NAME PHONE <br /> First M/ Last <br /> BUSINESS NAME . V�r LV-, WA 76 &kS 57A7r71ON (�b5+ TAX'D# _ <br /> CC`NVI=tJttl�fC4 RETAi��S <br /> Owner Home Address 32a� W I4>'cl�til��r{ LH DRIVER'S LICENSE# NA <br /> City SY6CKTON STATE L1 A ZIP '?5-20 7- <br /> Owner Mailing Address Po 60X' S9 3b5 <br /> Mailing Address City SC.HA U N1$fi{Z(, state I L Zip 6D I Sc. <br /> CORPORATION INDIVIDUAL❑ - PARTNERSHIP❑ FED AGENCY❑ OTHER❑ <br /> .FACILITY FILE �SSr /lGt�en2 14 �G 1.�5� <br /> !i <br /> FACILITY ID# i CRosB REF ID# ri AyuuNNT� INV# <br /> 1 <br /> COMPLETE THE FOLLOW/NG BUSINESS I FACILITY I SITE INFORMATION: <br /> I_s this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH YES ❑ ND ❑ <br /> IS this an EXISTING Business LOCATION but a NEW TYPE of regulated Business? YES ❑ No ❑ <br /> /� r <br /> BUSINESSIFACILnYISITENAME ; B? 111 !p 3 Q/Ct . SrAj4-re(- COMSO MNU 67RPOR A,-r(N _ <br /> SITE ADDRESS 320 2, W [4-A- lMtLR i.t SUITE# BUSINESB PHON(9l(j'166 i 0g0o <br /> CITY S-TOCK-110H STATE CA ZIP 015207 <br /> BOARD OF SUPERVISOR DISTRICT' LOCATION CODE KEPI s KEY2 - <br /> 1 <br /> Mailing Address ff DIFFERENTfrom FaellltyAddress Attention:or Care Of(optional) <br /> 3617 KR,60 -m 144 S+�i�?NZkr• Tl `FF v . <br /> Mailing Address City RAN C Ij p CO R M VA STATE (�Q LP t]b 70 <br /> SIC CODE APN# O Q e7�'�O O COMMENT: <br /> F� 1[ (J el- <br /> THIRD PARTY BILLING INFO: Complete if Billing Party is different from Property Owner or Facility Operator identified above. <br /> BUSINESS NAME STAMI-E-C. C09 5VLTl NC-1 COrz PdAA71 ON Attention:orCare Of (opdona!) <br /> 15BI Atu, .rlJ S(1ie', tr; <br /> Mailing Address 3O h Kl[,�QrLE K1> f SwC7 too PHONE ('q�� � 86I ^p�pd <br /> CITY RA-U(,iA'(5 COP-VovA STATE ZIP q.5670 <br /> ADG wrAODRm for fees and charges OWNER FACELITYIBUSINESS THIRD PARTY BILLING <br /> BILLING AND COMPLIANCE ACKNOWLEDGMENT: 1,the undersigned Applicant,certify that I am the Owner,Operator,or Authorized Agent of this Business,and I acknowledge that all PERMIT FEES, <br /> PENALTiEs,ENFORCEMEn7CHARGES and/or HOuRL3'CHARGES associated with this operation will be billed to me at the address identified above as the ACCOUNTADDRESS for this site. I also certify that all <br /> 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 facilitylsite address,1 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. JJJ <br /> S.TI'IZ'' a;l PLEASE PRINT <br /> APPLICANT NAME :$1� <br /> . 1/�i`'tK- SIGNATURE <br /> TITLE �$ i0 7ECIG-00715 i✓ �� 7 d z <br /> Appraved By Date ACcoulrting WHce Processing Completed By Date ( / <br /> 24-002 April 25.2003 <br />