BILLING - Laserfiche WebLink

Home Browse Search

San Joaquin County Environmental Health Department GREEN FORM DATE �S MASTER FILE RECORD INFORMATION "MFR" SE Fn ARFAC FnR FHn NGF nNl V OWNER ID# ��f l 3� ` l� r ' UNIT IV V"V J D ! i u I-M& OWNER FILE COMPLETE THE FOLLOWING PROPERTY OWNER INFORMATION; Jill CNECKIF OWNER CURRENTLroNFILEwITH EHD PROPERTY OWNER NAME 'n'Ca� ., i PHONE First Ml BUSINESS NAME �V�_ � SOC SEC/TAx ID# Owner Home Address I J2 G� 2(j—7 r [�-a DRIVER'S LICENSE# City / STATE/ /t ZIP Ov Owner Mailing Address f L l y ITT f� Mailing Address Cityg 3 State Zip T/DF nF nwNFR W r0 CORPORATION❑ INDMDUAL❑ PARTNERSHIP❑ FED AGENCY❑ OTBER❑ FACILITY FILE FACILITY ID# O D'Ip 33LfJ�w:-:TIDCROSS REF ID# # INV# COMPLETE THEF LLOWINBUSINESS I F CILITY I SITE INFORMATrON' Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ No ❑ Is this an EXISTING Business LOCATION but a NEW TYPE of regulated Business? YES ❑ No ❑ BUSINESS/FACILITY/SITE NAME _.�KJ ��K SITE ADDRESS -7 lll✓✓✓ --1UUJ SUITE# BUSINESS PHONE CITY \�J I✓O' 1 STATE ZIP BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEYL KEYZ Mailing Address ifDIFFERENTfrom FacilityAddress Attention:or Care Of(optional) Mailing Address City //�� STATE ZIP SIC CODE ::-:��]FPN# ✓Iy O �� COMMENT: THIRD PARTY BILLING INFO: Complete if Billing Party is different from Property Owner or Facility Operator identified above. BUSINESS NAME J ( f �(, AIC Attention:o�Care Of (optional) we—�t � r� jam(,Mailing Address I:'1PHONErC�in Cm r�1 i I rj�� STATEA uPqqbl dcccyNT w_^ /QRESS for fees�and charges OWNER FACILITY/BUSINESS THIRD PARTY BILLING RILI INC.AND Comp1.IANCF ACKNOWLEDGMENT: I,the undersigned Applicant,certify that I am the Owner,Operator,or Authorized Agent of this Business,and 1 acknowledge that all PER411T FEES, PENALTIES,ENFORCEMENT CHARGES and/or HOURLY CHARGES associated with this operation will be billed tome at the address identified above as the ArrnuNT AnnRF.C.0 for this site. I also certify that all information provided on this application is true and correct;and that aB regulated activities will be performed in accordance with all applicable SAN JOAQUIN COUNTY Ordinance Codes and/or 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 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 provided to me or my representative. � PLEASE PRINT APPLICANT NAME SIGNATURE 1,�1G� �.�►'U Z Z ' � TITLE J / ` DRIVER'S LICENSE# % 5 lj�Li o�-r LL�V L--`I I��41 � � �I 1 (PHOTOCOPY REQUIRED) Approved By Date Aaounting Office Processing Completed By Date Z 29-02-002 April 25,2003