Laserfiche WebLink
-1-1D5 <br /> San Join County Environmental Health Department <br /> GREEN FORM <br /> DATE MASTER FILE RECORD INFORMATION LLMFRf' <br /> GRencn eacec CAST FMn,ucr nxiv OWNERID# CASE# UNIT IV <br /> OWNER FILE <br /> COMPLETE TMEFOLLOWING PROPERTY OWNER INFORMATION; CNrcrrr•F OWNER CURRENTLYONFELEWEDI EHD ❑ <br /> PROPERTYOWNERNAME PHONE <br /> Flat MI Last <br /> BUsmess NAME 12 r^ 4:Z56 I at lin e C-OV n I !=7'�I SOCSEC/TAXID# <br /> Owner Home Address DRWER'S UaNSE# <br /> city STATE IIP <br /> Owner Mailing Address L� `�' <br /> Mailing Address City SS� L State <br /> rveF nanw ll.... 'rc7-1-T-' <br /> CORPORAIIDN INDIVIDUAL❑ PARTNERSHIP FED AGENCY❑ OTHER 11 <br /> FACILITY FILE <br /> FdcILRV ID# CROSS REF ID# AccounT ID# INV# <br /> COMPLMTHEFOLLOWrNG BUSINESS I FACILITY I SITE INFORMA770N.' �a <br /> Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ Noz <br /> Is this an EXISTING Business LOCATION but a NEW TYPE of regulated Business? YES ElNo,pi�af <br /> BUSa1Es5/FAm.TrY/SIrENAME <br /> SITEADDRESS �10 I SURE# 1 IP <br /> IS BUSINESS PHONE <br /> m' <br /> CM <br /> STAT Z9J ZI� <br /> BOARD OF SUPnNn.DLStaucr \ LOf Mhl CODE mi KEY2 <br /> Mailing Adoress O/fD FFERENTfTU Faci/ityAddress Attention:of Care Of(Optional) <br /> . d qac CSO I I <br /> Mailing Address City C h� STATE(S ZIP �` U <br /> SIC CODE 1, `-J APIC# COMMENT: lr` <br /> THIRD PARTY BILLING INFO; Completed Billing Party is different from Property Owner or Facility Operator identilled above. <br /> BusulEss NAME CS Attention:oFCare Of (optional) <br /> VS fa, <br /> r I <br /> Mailing Address 12 ,,yam. 4 T 12 PHONE <br /> CRY G ✓ l ���"`CCL.. \ ATI�(� ... J Ll / <br /> � ) cJ <br /> A yr AOtm for fees and Charges OWNER FACILITY/BUSINESS THI D PARTY BILLING <br /> RTI.r me ANn COW lAAN"Ar wGW l rncMEW: I,the undersigned Appgcan4 certify that 1 am the Owner,Operator,or Authodaed Agent ofthis Business,and-1.clmowledge that ell PERMS FEES, <br /> PENALTIES,EN£ORCEMENTCHMGEF and/or Houn)`CRARGw associated with this operation will be billed tome at the address identified above as the Ata nuWADDRF.ee for this site. 1 also certify thal <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 end/or <br /> Standards and STATE andlor REH RAL Laws and Regulations. As the undersigned owner,I�t lQrg e p ted at the above facility/she address,I hereby author¢¢the release of <br /> any and All result and envins..mal assessment information to SAN JOAQUIN COIm V V 1 ,1 E✓� EPART as soon as i ,a 'le a and at the same Nme it is <br /> provided to me or my representative. <br /> piluNT <br /> APPLICANT NAME /.'^�L..,e �� _ SIGNATURE rl�l�{/� /p/{//�� ✓/( <br /> TITLE \ 0 q l ((M DRIyOTOWopY ilE EUIRED) y.JV r.-- • E 1 <br /> Approved By V Vale 1 Aaounbng Ocoee lava sing Completed By _ Data <br /> 29-02-002 April 25,2003 <br />