Laserfiche WebLink
San Joaquin County Environmental Health Department <br /> GREEN FORM <br /> DATE (�G1 MASTER FILE RECORD INFORMATION "MFR" <br /> UNIT IV <br /> OMM PILE <br /> MWIM' Omorrf OWNER CIN"NRYOMf EWrTH EMD <br /> Ft MM"owes?HAM FlO►e <br /> First W1 Lest <br /> etre NAM SOC S-/TAg M* <br /> Ow ter Home Address DWER's LJCEPM aX <br /> Oh STATE ZIP <br /> Omens Meq Address <br /> Mselnp Addrea CRy <br /> 14- stale Zip <br /> CO 00"Taw❑ VWEVID4K❑ PAKrNEm5KtP❑ F®AM-ICY❑ Onmt❑ <br /> FACILITY FILE <br /> Is(his a NEW LDaTION?tot pr-Ylo I replalieted by the ENVIRO/MIBfTAI HEALTH DEPARTMENT? res ❑ No —/ <br /> Is this an Elasrins aueknee LocATION but a New TYPE of regiiidwW Busklees7 res ❑ NO Ly <br /> Wo /FACLM/SM HAM N r <br /> S-A-- sem[* BUSVMS PHW �, ^ <br /> CITY STATE <br /> 1 � 1 T• f <br /> Is& Address A'0D7t9 tT/larr A hdWWAd3ea Attention:or are Of(apdonn) l 1 <br /> OWN Address Oty u STATE / <br /> q <br /> Tsu pART1f Swum INroo'CaWlele/f BINI g Party lisd#?&Iefftftm Property OWIW arF <br /> aciBty Operator b(enb'Ifieid above. <br /> Mala NASE I !!i I �Gt V Atamloe:*rare Of�(qudona1 <br /> Mm%V Address G `7 <br /> CITYSTAT! ZIP /T <br /> ��ztIL4w <br /> AQQmwxLAi:ii;mitiiiiiii�1br?lees and charges OWNER FACILITY/BUSINESS TNIRO PARTY BALING <br /> nt crate.leen r'ruvvdi•r_rr AfXNftWt•arses-:.; 1,the nadersipted Applicant,certify that I am the Owner,Operator,or AuAorfiedAgent of this Business,and 1 acknowledge that all PERAorFEES', <br /> PENACTTES,ENPURC'EM ENTCHARGES sad/or HOURLY CHMGET associated with this operation will be billed tome at the addresa idmtified above As,the ACCOUNTAMIJIF,ST for this sits 1 also certify thad <br /> au information provided as this application is true and correct;and that all regulated activitim will be performed in accordance with■11 applicable SAN JOAQUIN COUNTY Ordinance Codes and/or <br /> Standards and STATE sod/or FTDERAL Laws and Regulations. As the undersigned owner,operator,or agent of the property located at the above facilitylsite address,I hereby oulhoritr the release of <br /> May and as resstls sad environmental assessment information to SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARENT n soon u it4 waliable nd at the ume time it is <br /> Qrovided to we ler myr tsti'e. / /`gv'II J <br /> AMIICANTNAME I �IIV �Ft SIGNATURE <br /> Tnu , S A w/ DRIVERS LICENSE <br /> 1' ► �1' (r+fot000►r REgimtml <br /> bt•�M Deis Amsawliq Office►rowsiq Corstpls0ad M wee <br /> 29-02-002 April 25,2003 <br />