Laserfiche WebLink
San ituin County Environmental Health Gepartme cI�rGk1=t�t�11d�Iwl <br /> DATE , °Z Z NO MASTER FILE RECORD INFORMATION "%MFRY' (�; <br /> OWNER ID# CASE# A ��) I U�V <br /> �EIIFn eRFe5 EOR FHn USE IINI V I-r —1 3 N4 I} I I- <br /> lls l` J PEij(';1/�I I%JC.il�l CFS <br /> OWNER FILE <br /> CHECK IF OWNER CURRENTLYON FILE WITH EHD <br /> COMPLETETHEFOLLOWINGPROPERTY OWNER INFORMA710N; <br /> i?� S 1. PHONE �ll CI 1 <br /> PROPERTY DINNER NAME ��-n/ � i r( S � �\ (?Gl} �S(� r <br /> First MI Last <br /> SOC SEC/TAx ID# <br /> BUSINESS NAME I ^ <br /> I'j <br /> drs1�3. <br /> DRIVER'S LICENSE# <br /> Owner <br /> me <br /> odec STATE <br /> '- <br /> city <br /> C rn' <br /> Owner Mailing Address <br /> State zip <br /> Mailing Address City <br /> TVDF AF(rW NFRCNTp <br /> ❑ ❑ <br /> PARTNERSHIPI,I FED AGENCY El OTHER <br /> CORPORATION INDIVIDUAL <br /> ❑ <br /> FACILITY FILE <br /> �J INV# <br /> CROSS REF ID# 7 <br /> ACCOUNT ID# 'S(� <br /> FAQLrIv ID# 1� <br /> JJJJ <br /> COMPLETE THEFOLLOWING SITE NF RMA71 N' <br /> Is this a NEw Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ No <br /> Is this an EIaSTING Business LOCATION but a NEW TYPE of regulated Business? <br /> YES El No ❑ <br /> BUSINESS/FAcI rn'/SITE NAME <br /> 1 SUITE# BUSINESS PHONE <br /> SITE ADDRESS � � ) � n)I� `/ C ('/1 <br /> Cm STATE(A ZIP <br /> BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEYS <br /> KEYz <br /> Mailing Address if DIFFERENT FcilKyAddress <br /> rrtion:orCare Of(optional) <br /> STATE ZIP —7, <br /> Mailing Address City �r- <br /> SIC CODE d C)\-k APN# UD31 SD �' COMMENT: <br /> THIRD PARTY BILLING INFO: Complete ifBilling Party is different from Property Owner oorrFUaocnlityCOperaare Of t�da)tifiedabove. <br /> BUSINESS NAME <br /> ---- <br /> PHONE <br /> Mailing Address <br /> STATE ZIP <br /> CITY <br /> eCCnrMgADnvccc for fees and charges OWNER FACILITY/BUSINESS THIRD PARTY BILLING <br /> 1111CiI 1 ING AND UMPI]A CE ACKNOWI E12FMENT: 1,the undersigned Applicant,certify that I am the(honer,Operator,or Authorized Agent of this Business,and I acknowledge that all PERAHTFEEs, <br /> PENALTIES,ENFORCEMENTCHARGEs and/or HOURLY CHARGES associated with this operation will he billed to me at the address identified above as the Arco rNTjL?L .S for this site. 1 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 Robve facility/site address,1 hereb uthorize the release of <br /> any and all results and environmental assessment information to SAN JOA COUNTY ENVIRONMENTAL HF.ALTII DEPA/R}TA E 'as soon as it is available- at the same time it is <br /> provided to me or my representative. �` ' <br /> l P SE PRINT SIGNATUR �i�/ <br /> APPLICANT NAME n ' 1 LA"J � <br /> TITLE U DRIVER'S LICENSE# <br /> (PHOTOCOPY REQUIRED) <br /> Approved By .CL- Date T Z D Accounting Office Processing Completed By Date <br /> 41 <br /> 29-02-002 April 25,2003 <br />