Laserfiche WebLink
San Joaquin County Environmental Health Department <br /> HATEGt�,EEPd F�RnI; <br /> WASTER FILE RECORD WORMATION "MFR" <br /> yNADED AREA9 FOILEifp U8E ONLY. i T IV <br /> OWNLR IDN i CASE# U+ `I i <br /> OWNER FILE <br /> COMPLETE THE FoLw*wG PROPERTY OWNER/NFORM47ION: CHECKtF OWNER CuRREArrcroNFxEwn N EHD <br /> PROPERTY OWNER NAME ,-.--_ ^,.....a -"—ac:.ie 7--,-, d,%/ PHONE "> f ?37 <br /> Fifst M.l Last <br /> BUSINEss NAmE .. "F 3. ,., �Tr Y.- Soc SEC/TAX ID# <br /> Owner Home Address DRIVER'S LICENSE# <br /> sky STATE LP <br /> Owner Mailing Address <br /> Mailing Address City _ She ZIP <br /> CORPORATION❑ INDIVIDUAL u PARTNERSHIP❑ FED AGENCY❑ OTHER❑ <br /> FACILITY FILE <br /> FACILITY ID# CRosa REF ID# ACCOUNT ID# <br /> P ,�z <br /> COMPLETETHEFOLLOW/NG BUSINESS 1 FACILITY 1 SITE INFORMAT/oN: <br /> Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPT.? YES ❑ No ❑ <br /> Is this an E STING Business LOCATION but a NEW TYPE of regulated Business? YES ❑ No <br /> BUsINESS/FAG'ILITY/Styr.NAME ` F� .�- 5.�cAc+vv`, <br /> / 1111 l.1 <br /> DO <br /> SITE ARES: � ✓V .� �r $URE# BUSINESS PHONE <br /> CITY 5+0 C- STATE LP <br /> h i <br /> BOARD OF SUPERVISOR DISTRICT LoOATM CODE KEY1 KEY2 <br /> Melting Address HDIFFERENThvm Fac/t/lyAd&vm Attention:or Care Of(Ooblanao <br /> Mailing Address City STATE LP <br /> rEsicODE APN# COMMENT: <br /> THIRD PARTY BILLING: INFO.' Complete ifBilling Party is different from Property Owner orFacifity Operator idenfif/edabove. <br /> BUSINESS NAME •" _ Attention:orCare Of(op4t mi) <br /> /y <br /> Halling Address —' x _ PHONE f G "1 <br /> STATE �;i ZiP 1715-16, <br /> for fees and charges OWNER FACILi fi v BU&NESS THIRD PARTY BILUNG <br /> BI.LLINC AND CoMPt tANcr•.ACKNO�t7.ET)GmEN'T: 1,the undersigned Applicant,certify that I am the Owner,Operator,or Authorized Agent of this Business,and I acknowledge that all PE.RAfTT Frsrs, <br /> PE.vALTm5.E:vFoRcE.wEA7 CHARGFB and/or ffot�at.r CHARGES associated with this operation will be billed to me at the address identified above as the ACCOUA7ADDRF_TS 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 /> Standardsaed STATE and/or FEDaILLL Lao's and Regulations. As the undersigned owner,operator,or agent of the property located at the above facilitylsite address,I hereby authorize the release of <br /> any and all results and environmental assessment information to SAN JOAQUIN COUNTS'ENN BONN ENTAL f1EALTII DEPARTM1iENT as soon as it is available and of the same time it is <br /> provided to me or my representative. <br /> APPLICANT NAME PLEASE PRINT SIGNATURE <br /> J DRIYER'SUCENSE# ._ <br /> TITLE r <br /> ,r. '.'�•.-^,'_.. f�' .,:,-•a p_ _ ;-'�`_^C: ', -''� (PHOTOCOPY REQUIRED) <br /> Approved By Date �I Accounting Office Processing Completed By - Date <br /> 29-01 I0r12i07 �tASTF.k FII..E RECORD-GREE <br />