Laserfiche WebLink
San .ruin County Environmental Healtleepartment <br /> GREEN FORM <br /> DATE MASTER FILE RECORD INFORMATION "MFR" <br /> QHGO n ARFDC FO1 7 /_R FHn IICF nNl Y OWNER ID# Q CASE# UNIT IV <br /> ( !�/ OWNER FILE <br /> COMPLETE THE FOLLOWING PROPERTY OWNER INFORMATION: CHECKIF OWNER CuaRENTLYoNFrcEwrm EHD <br /> El <br /> PROPERTY OWNER NAME PHONE <br /> o 6( 6 -b <br /> First MI Last <br /> BUSINESS NAME SOC SEC/TAx ID# <br /> Owner Home Address O \ DRIVER'S LICENSE# <br /> City STATE C n ZIP - <br /> Owner Mailing Address <br /> �•c7 • o Z o8`1 <br /> Mailing Address City ` ` State Zip S 2 0 1 <br /> TYPF OF nWNFRCHTP �7 �y <br /> CORPORATION❑ INDIVIDUAL El PARTNERSHIP El FED AGENCY❑ OTHER►d! <br /> FACILITY FILE <br /> FACILITY ID# ] I ACCOUNT ID# q p—D INV# <br /> ��q <br /> COMPLETE THEPOLLowiNG BUSINESS I FACILITY SITE INFORMATION: <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/SITE NAME <br /> SITE ADDRESS SUITE# BUSINESS PHONE <br /> CITY STATE ZIP <br /> BOARD OF SUPERVISOR DIsiRICi LOCATION CODE KEY1 ICEY2 <br /> Mailing Address ifDIFFERENTfrom FacilityAddress Attention:or Care Of(optional) <br /> Mailing Address City STATE ZIP <br /> LSIC CODE APN# COMMENT: <br /> THIRD PARTY BILLING INFO: Completeif Billing Party is different from Property Owner or Facility Operator identified above. <br /> BUSINESS NAME Attention:or Care Of (optional) <br /> E�J� ►��.,A.,.ems.�.\ '�-��s�- �� d` c e1g f o � <br /> MailingAddress PHONE <br /> 2 -2- <br /> CITY <br /> O 2 �l �j �L�oGc'� <br /> CITY �)Q\•l K t L t-e—G STATE c A ZIP —l 4 <br /> e.vv,1=4opgus for fees and charges OWNER FACILITY/BUSINESS THIRD PARTY BILLING <br /> RnuNc AND(ontPi jANCE ACKNOWLEDGMENT: I,the undersigned Applicant,certify that I am the Owner,Operator,or Authorized Agent of this Business,and I acknowledge that all PERMn'FEEs, <br /> PENALTIES,ENFORCEMENT CHARGES and/or HOURLYCHARGES associated with this Operation will be billed to me at the address identified above as the AA'CYIUNT AD 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,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. (q2 f)- ?0—16,00 >'/0' <br /> PLEASE PRINT SIGNATURE <br /> T <br /> APPLICANT NAME 1 �So m —" (�l' )fig(,-Sz30 <br /> TITLE DRIVER'S LICENSE# <br /> (PHOTOCOPY REOUIRED) <br /> Approved By Date Accounting Office Processing Completed By Date (� <br /> 29-02-002 April 25,2003 <br />