Laserfiche WebLink
C�r--r San Joaquin County Environmental Health Department� <br /> GREEN FORM <br /> DATE � p MASTER FILE RECORD INFORMATION "�MFR" J�,l� 2007 <br /> Suenrn aaFsc FOR PHn use Oxiv OWNER ZD# ,� CASE# F9�J <br /> �1 a Jl <br /> OWNER FILE <br /> COMPLE7L=7HEFOLLOWINGPROPERTY OWNER INFORMATION; CHECKzr OWNER CvRRFNrcroNFrLEwrrN E^HD <br /> PROPERTY OWNER NAME PHONE <br /> First Ml Last !!// <br /> BUSINESS NAME Q �^ SOC SEC/TAx ID At <br /> owner Home Address 'Z-540"D <br /> ZJ 5Y��Jt_/ �D 6( t_O„4' 1 J DRIVER'S LICENSE# <br /> City �C JlrSTATE ZIP <br /> Owner Mailing Address <br /> [Mailing Address City \Q V--r' Dr t° State A L <br /> TYPE EQWNERSHIP <br /> CORPORATIONS ImorvmUAL❑ PARTNERSHIP❑ FED AGENCY❑ OTHER❑ <br /> FACILITY FILE <br /> FArnrrY ID# °` CROSS REF ID# AcoouNT ID# INv# <br /> COMPLE7UNEFOLLOWMG BUSINESS I FACILITY I SITE 1NFpRmA7:ToN- <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? �t YES-® No ❑ <br /> BUSINESS/FACMM/SITE NAME tit c�. ��S, ��l�r� ��.Cp�` M •� G�i� \ <br /> SITE ADDRESS v �� `'! \. _-90M# _. BUSINESS.PHONE. . <br /> CITY ITC` �1� By�G_sd STATE �--A ZTP !5 3 <br /> BOARD OF SUPERVISOR DISTRICT \ LOCATION CODE KEY1 KEY2 `, <br /> Mailing Address ifDIFFERENThnm Fac W.Alddhess Attention:or Care Of(optfona/) <br /> a S" t� ;� c, s oa <br /> Mailing Address City STATE <br /> SIC CODE -APN# COMMENT:rN <br /> THIRD PARTY BILLING INFO: Complete if Billing Party is different from Property Owner orFacility Operator identified above. <br /> 13usINEss NAME �� � Atg"Ttio`n�orfare Of�pdona/) <br /> [Mailing Address <br /> CITY STATE ZIP <br /> VJ <br /> for fees and charges OWNER FACILITY/BUSINESS THIRD PARTY BILLING <br /> nII 11NG ANI ComPTIANCF ACKNOWI.FDGMFNT: I,the undersigned Applicant,certify that I am the Owner,Operator,or Authorized Agent of this Business,and I acknowledge that all PERMIT FEES, <br /> PRNALTLFS,ENFORCEMENT CHARGES and/or HOURLY CHARGES associated with this operation will be billed to me at the address identified above as the Accur,NrAnp 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,I hereby authorize the release of <br /> any and alt results and environmental assessment information to SAN JOAQLTIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it' vailable and at the same time it is <br /> provided to me or my representative <br /> APPLICANT NAME ��Q� r „y-e— SIGNATURE <br /> TITLE ^ y^ DRIVER'S LICENSE# <br /> 6.e?—et) (PHOTOCOPY REQUIRED) <br /> Approved By Date Accounting Office Processing Completed By Date <br /> 29-02-002 April 25,2003 <br />