Laserfiche WebLink
FEB, 22, 2005 12:57PM CONDOR EARTH TE , <br /> >?h.�.rt?,.oxV.:::..... <br /> • " 7+ �^ >r,cx: 'iY: Sx. .. •..� .::� -- ... FORM { GD75f VI3ED `171 <br /> RECORD INFORMATION <br /> °r UNIT IV <br /> - <br /> OWNER FILE <br /> CHECKJF OWNER GURRENrt,IONFILE wIYMEHD <br /> COMPLEI'ET'HEFOLLOW/NG BUSINESS OWNER INI=ORMATION: ..............n rrrr,r«....__._.�nu..ur.rrrn. ...._........_............. <br /> ___.........._.�._.,,.r. n <br /> .u.,r... <br /> PHONE <br /> Bu3INES3 <br /> ..i--� ———— -- L-V�— ✓ �� �� <br /> OWNER NAME: `— ----�" J <br /> first ,M ....._ .........-b°st�........�----�.. <br /> ^� W.... �_..1...._..V-`�..._... <br /> BUSINESS NAPE(if di/1'errentfrom owner Name) ,Y SOCSCO/TAXID* <br /> rnUNil Gt o� 171 Tr-t L� <br /> ' <br /> DRIYER'BLCEN9E <br /> OWNER HOME ADDRESS <br /> i STATE ZFP q 5 (D <br /> city <br /> OWNER MAILING ADDRESS [ifDIFFERENrfrom OuwnerAddress) Attention-orOare of (OPd0Ra/I <br /> Mailing Address City ' State zip <br /> CORPORATION Q r INDENDUALQ PARTNERSHIP❑ LOCAI.AGENCY COUNFYAGENCYQ sTATEAeENCY❑ FEOAGENCY 0 OTHER❑ <br /> FACILITY FILE <br /> RM a <br /> COMpLETE7-HEFOLLOWING BUSINESS I FACILITY I SITE INFORMATION-- <br /> is <br /> NFORMATION-Is this a New Buainess LDOATION not PrerdO11115ty regulated by the ENVIRONMENTAL HEALTH DIVISION? YES ❑ No <br /> is this an STING BUSinMS LOCATION buta NEW TYPE Of MVMI*0d Business 7 YES ❑ No 1 <br /> BUSINESSIFACILITY/SITE NAME: �A (lL &, 4 — <br /> `J— r-�� SUAIT�E tv� i BUSINESS PY.ONE A\/r <br /> $ITE ADDRESS _\ fQA►^ . �) �d. A '� 1 I�ai�A�l ►i fir, V 1� '. <br /> PACITY �ii �J`J SIA ZIP <br /> �+e:p 0 VN_ <br /> „�., c .:rxn.:.Yp�;,,<ax«o"03� a. ».a< '0✓.::. �' x ..,..,n.c o-._ •��-�.,4•�,M m�w-�"�'.i6�&;.. mak... x�'. <br /> Mailing Address ifOIFFERE1Vrfrom FacililyAddrass 1 Attention:or Care Of(aptivrrar) <br /> Mailing Addrea;Cir $CATtc zip <br /> THIRD PARTY BILLING INFORNAMON; Complete if Billing Party Is different from Business Owner Idenl�ed above. <br /> - n —_—.........r. W.nnnIc 12 ��C <br /> SualNess NAME AttAMlon:trrCare Of (opbor+srJ <br /> Mailing Address 1Q�{ _ lI t -1a� �`�,1�\ �1 PHONE 209_�����`L7 - <br /> Circ 1 cGlr\v V f Cnn/�F� W c.71 C sTATE/r dy zip <br /> LA� iiiiiiiiiiiinumi <br /> ,ADDaEss for fees and charges OWNER FAcuTYBUSINESS THIRD PARTY BILLIRIG <br /> BILL AND COM. .Inticr I,the undersigned Appli,-nr,certify-that 1 am the Owner,Opzrarop,or A d&pri:ed--rent of Ibis Bds iness,and I ad:nuwlodae that all <br /> PERAUr FrES.PS.uAI MS,P.VF0RCEAMvT 0UPIriSS and/or!HOURLY CHARGES assoGialed with this operation will be billed to me at the addrm-c Identified above as the AGY ouvr <br /> nREIS ror this site I also c7rtKy that all inrorrrmatinn nmvi�ina on rhi�sppFication iK true and cortecL and thst all re?ulated activities*0 be performed in accordance with all <br /> applicable SANJOAQUIN COIMY Ordinance Codes;ltd/or Standards and STAT&9nd/or FEDERAL Laws and Regulations. As thu undersigned owner,operator.or went of the property <br /> located at the above racilirylsite address, 1 hereby authorize the release or any and all rieuits and environmental assessment information to SAN JOAQUIN COUNTY <br /> E(V[RON41E,NTAL HP_AI j7i DIVISION as soon n it is available and at ibc same time it is provided to me or my rcprescntativ <br /> PLEASE PRINT <br /> APPLICANT NAME = ldr/\. SYS GhS SIiGNATURE <br /> DRIVER'S LICE SE 9 • V ( I f 2J/S <br /> TITLE �Owrrrnrnor At'dUlttFltl r/ / 4 <br /> x k3` w�. )°' rR �,•7, x'y 'i..-;:.�.aieo�r vei„<.`.`•y^"°°�, � <br /> n�rw a`*`# 3 :s �akb 1'r..s+h4 •tl'LS= E• .fifIIGd.> t'jl :3. Va <br />