BILLING - Laserfiche WebLink

Home Browse Search

' t San Joaquin County Environmental Health Department GREEN FORM DATE MASTER FILE RECORD INFORMATION "MFR" GUAncn AUFA%Fna FHn o%F nei v OWNER ID# 13zZ-c CASE# UNIT IV {{{{✓ OWNER FILE /. COMPLETE THE FOLLOWINdG/PROPERTY OWNER INFORMATION: CHECKIF OWNER CuRRENTcroNrzLEwrTH EHD ❑ PROPERTY OWNER NAME r- Ir E ^,'„ �` PHONE 1- , Fiirrstt M1 r4 7Last BUSINESS NAME Soc SEc/TAx ID# Owner Home Address DRIVER'S LICENSE# city ,� � STATE/ zip Owner Mailing Address � ) / Mailing Address City f 1 per,,,,, l State- Zip 5 �� TYar to nwucacuro CORPORATION❑ INDIVIDUAL0I PARTNERSHIP❑ FED AGENCY❑ OTHER❑ FACILITY FILE Cyt FACILITY ID# j/_"3 t4 CROSS REF ID# ACCOUNT ID# �y'_'�/� INV# 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 SITE ADDRESS SUITE# BUSINESS PHONE CITY STATE I STATE/' U 4—Dp ` 2, BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEY! KEY2 vl` Mailing Address ifD1FFERENTfiom fad/ityAddress Attention:or Care Of(optional) Mailing Address City STATE ZIP $IC CODE APN# 11�I Z0 t-)Z3 11 COMMENT: THIRD PARTY BILLING INFO: CompleteifBilling Party is different from Prop(efrty 0wn1er/orFacility Operator idendfied abo ve. BUSINESS NAME _ Attention:orCare Of (optional) s rr1Lam �!Ausew5 Mailing Address 1000 SLU-r57 DOO PHONE(5 16 OZro9? 461 CITY O STATE ZIP/4t;c,E4u� er aLmge DRm%for fees and charges OWNER FACILITY/BUSINESS THIRD PARTY BILLING Bn L rvc ANn COnIPI IANt'F ACSNOWLTnc MFNT: 1,the undersigned Applicant,certify FS that 1 am the Owner,Operator,or Authorized Agent of this Business,and I acknowledge that all PERMIT FE , PENdLTIFS,ENFORCEMENT CHARGES and/or 1101rRL v CHARGES associated with this operation will be billed to me at the address identified above as the ACCOLYTADDRFCS for this site. 1 also certify that 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 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 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 PRIM le APPLICANT NAME L=am IQ D * `a I'N)SO SIGNATURE C�C� Q 'y�]�. TITLE Nz-c J &<�v (^y)r,_ `^ `� (PHOTOCOPY OCOPY REOUIR DSE) R 3 / / Q ? Q / 11 Approved By Date 1 N IA(J l.J 1` Accounting Office Processing Completed By Date 29-02-002 April 25,2003