Laserfiche WebLink
Nov 29 05 12:48p Peter Weiler- • (925) 938-1610 p.3 <br /> San Joaquin County Environmental Health Department <br /> GREEN FORM <br /> DATE ��`✓ MASTER FILE RECORD INFORMATION "MFR" T <br /> r%RAnFn ARFle Fna FNn 1<F nN1Y OWNERID# -7q CASE UNI • 'V <br /> ll OWNER FILE <br /> CxccxrF OWNER CuRRerortroNFrtewmr EHD <br /> COMPLE7FTHE FOLLO14WGPROPERTY OWNER INFORMATION,I <br /> PRCaE RTY OW NFR NAME <br /> First MI Last PHONE <br /> BusmEss NAME o r c ! J ( n _([l IS• Soc SEc I TAx ID# <br /> Owner Home Address 2 2�1 ORrvER's L[cENSE# <br /> STATE ZIP <br /> City � � f7 Z�� <br /> Owner mai Ing Address <br /> Mailing Address City State ZIP <br /> TMEOF tIMMELS na <br /> CORPORATION Ll INDIVIDUAL❑ PARTNmsHxP V FED AGENCM� OTHER <br /> FACILITY FILE r�n r� <br /> 1 I CRO5�rt7EIID <br /> # ACCOUNT ID# J`7 •�S �11NV# I I L L'!, <br /> FACILIT'I ID# 10 10 T LLL ✓ l"'� `(. <br /> QMPLETE EF LLGWINNFss I FACILTTY I SITE NFORMATI N• <br /> Is this a NEW Business LOCATION not previously regulated by ttte ENVIRONMENTAL HEALTH DEPARTMENT? yEs C No ❑ <br /> Is this an ExLsT mG Business LocATioN but NEWTYPE of regulated Business? �IYES ❑ NO <br /> INL.1 <br /> L❑� e <br /> BUSESSIFAaLIrrfSm NAME �.1-1� 1 L.1 (.A � k l ( 'e r � 1. 1 " , <br /> UITE I BuSINESs PHONE <br /> SITE ADDRESS <br /> CnY `7 �'IC�C- �—'11P._.'� �✓� � STATE ZIP <br /> BOARD OP SUPE�V150rc DISTRIcf tACATION CODE KEYI F(E'l2 <br /> MailingAddress ffDIFFERENT from Facility Address Attention:or Care Of(opWwl) <br /> Mailing Address City STATE ZIP <br /> sic CODE APN# CDMNE Yr: <br /> THIRD PARTY BILLING INFO: Complete if Billing Party isd#?L-rentfrom Property Owner or Facility Operator rdenh;uedaboue, <br /> BUSINESS NAME Attention:or Care Of (optiortat) <br /> to d t----\ tee.✓ l S 4� �-1 •C.-s3 L(?> <br /> Mailing Address 2 Z l f ( e j _ -L-0 PHONE <br /> c"„ tJ 4 ( k <br /> q.vvvrur aoRZ.,c forfees and charges OWNER FACILITY1BUSINESS THIRD PARTY BILLING <br /> Rn t w[�Nn{'OMPI tANCF 4[xt(nat 1,the undersigned Applicant,certiry that I an,the Omaer,Operator,or.4uthori„edAgenf of this Business,and I acimowledge that RU PMJ71 F7:Fs, <br /> PE"L7M,ENF0RCFMZNTL7L4RGFs and/or HOURLYCHARGES associated with this operation wffl be billed to tae at the address identitiied above as the A I-COU"T.LDRFSC for this site. I also certify[flat <br /> a6 informa0mn pzovided on this application is true and correct and that all regulated activities will be performed in accordance with all applicable SANJoAQuv�COUNTY Ordinance Codes and/or <br /> Scaodards and STATE and/or M, 1RAL Law.and Regulations. As the"dersigned owner,operator,or agent of the pr nperty located at the above facility/site address,1 hereby authorize the release of <br /> aoy and all results and environmental assessment information to SAN JOA QUI\COUN"ry ENV fRO:NMMNTAL HEALTH DEPARTMENT as soon as it is aifnb a and at the same tune it is <br /> pros{ded to me or"representative_ LEASE PRINT <br /> APPLICANT NAME '- t, o.� SIGNATURE <br /> TITLE C DRIVER'S LICENSE# r <br /> � e� p (PHDrocopvRlouMD) !! <br /> Approved By Date r D Accounting OtTke Processing Completed By _ Dato i 10 <br /> 29.02.002 April 25,2003 <br />