Laserfiche WebLink
San Jh..quin County Erwitonrnental Healtr epartment <br /> DAT GREEN FORM <br /> MASTER FILE RECORD INFORMATION "MFR" <br /> OWNER ID# - <br /> " UNIT IV <br /> OWNER FILE <br /> COMPLETE THE FOLLOWING PROPERTY OWNER INFORMATION; CHECKIF OWNER CURRENTLYONFILEWLTHEI-ID ❑ <br /> PROPERTY OWNER PHONE <br /> NAME <br /> First MI last <br /> BUSINESS NAME SOC SEC i TAX ID# <br /> Owner Home Address DRIVER'S LICENSE# <br /> City STATE ZIP <br /> Owner Mailing Address <br /> Mailing Address City state Zip <br /> TVPF nF nwmFRCMTC <br /> fnPPr10�1Tnw❑ Twnnnnnei ❑ PePTucocw'.❑ Fcn Af.CNry❑ rTTHCP❑ <br /> Far-11 Ilry Fill F <br /> FACILITY ID# CROs REF ID# AccouNTID# INV# <br /> COMPIELE <br /> Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ No ❑ <br /> Is this an EXISRNG Business LOCATION but a NEW TYPE of regulated Business 7 YES ❑ No ❑ <br /> BUsINEssi FACILrrYiSITE NAME <br /> SITE ADDRESS SUITE# BUSINESS PHONE <br /> CITY STATE ZIP <br /> BOARD OF SUPERVISOR DISTRICT I LOCATION CODE I ( KEPI I ` KEY2 I II <br /> Mailing Address ifoIFFERENTfrom Facility Address Attention:or Care Of(optional) <br /> Mailing Address City - STATE ZIP <br /> SIC CODE APN# COMMENT. <br /> THIRD PARTY BILLING INFO: Complete if Billing Party is dib`erentfrom Property Owner or Facility Operator identified above. <br /> BUSINESS NAME Attention:or Care Of (optional) <br /> Mailing Address PHONE <br /> CITY STATE ZIP <br /> effnTrAtr Ar1r10FES for fees and charges OWNER FACILITYIBUSINESS THIRD PARTY BILLING <br /> : ],the undersigned Applicant,certify that I am the Owner,Operator,or Authorked Agent of this Business,and I acknowledge that all PERsnT FEES, <br /> PENALTIES,ENFORCEMENT CHARGES and/or HOURLY CHARGES associated with this operation will be billed tome at the address identified above as the A rr'ouyr AnnMESS 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 COL\TY 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 fs available and at the same time it is <br /> provided to me or my representative. <br /> PLEASE PRINT <br /> APPLICANT NAME SIGNATURE <br /> TITLE DRIVER'S LICENSE# <br /> (PHOTOCOPY REOUIRED) <br /> Approved By - pate Ac nting office Prooessing Completed BY _ _ Date <br />