Laserfiche WebLink
t rA <br /> San uin County Environmental Healtl, ?artment <br /> DATE GREEN FORM <br /> 0 ;� MASTER FILE RECORD INFORMATION "MFR" <br /> SHADED AREAS FOR EHD USE ONLY ` <br /> OWNER ID# ,�`,F��: i.� z°.-r CASE At UNIT IV <br /> v� <br /> OWNER FILE <br /> p CHECKIF OWNER CURREN7ZY0NFILEwr7HEHD ❑ <br /> COMPLETE THE FOL'p rIIVG PROPERTY'OWN E R INFORMATION: <br /> PROPERTY OWNER PHONE <br /> NAME �OU (',q39 ) <br /> First MI last <br /> BUSINESS NAME SOC SEC/TAX ID# <br /> Owner Home Address /7C�1 DRIVER'S LICENSE# <br /> city �' b VlJ --ll`. STATE ZIP 9 S-3 <br /> 774 :j <br /> Owner Mailing Address <br /> �h�mr M AP,ov,. <br /> Mailing Address City State Zip <br /> TYPE OF OWNERSHIP <br /> CORPORATION❑ INDIVIDUAL - PARTNERSHIP❑ FED AGENCY❑ OTHER❑ <br /> FACILITY FILE <br /> FACILITY ID# L��/�.7% CROSS REF ID# ACCOUNT ID At �3�� INV# S <br /> COMPLETETHEFOLLOWING BUSINESS/ FACILITY/ SITE INFORMATION; ` o� <br /> Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES No ❑ <br /> Is this an EXISTING Business LOCATION but a NEW TYPE of regulated Business? YES ❑ No <br /> BUSINESS/FACILITY/SITE NAME <br /> — <br /> ve I OL <br /> SITE ADDRESS SUITE# BUSINESS PHONE <br /> I y8�� We-46ra,l�- Linc- �oa � <br /> CITY ... STATE ZIP <br /> J ca C� (�J <br /> BOARD OF SUPERVISOR DISTRICT I LOCATION CODE KEY1 KEYZ d`� <br /> Mailing Address WDIFFERENTlrom FacilityAddress Attention:or Care Of(optional) C— <br /> Mailing Address City STATE ZIP <br /> SIC CODE APN# COMMENT: <br /> THIRD PARTY BILLING INFO: Complete if Billing Party is differentfrom Property Owner or Facility Operator identif�above. <br /> BUSINESS NAME I / Attention:orfCarel Of (optional) CO <br /> L.�2VT9✓1 �v1Vi4'(I,'1VYL°N'FOt' �l�uNO Err�h7 Ulmer uv'�. h(�CJ�tT ���, Vic� <br /> Mailing Address PHONE <br /> rosy 0��'� B�vc 6C,1a �9 rya- I39 <br /> CITY STATE ZIP <br /> ave RcAw10v1 ola <br /> AccouNTADDREss for fees and charges OWNER FACILITY/BUSINESS {THIRD PARTY BILLING <br /> BILLING AND COMPLIANCE ACKNOw'LEDGMENT: 1,the undersigned Applicant,certify that I am the Owner,Operator,or Authorized Agent of this Business,and I acknowledge that all PERMIT FEES, <br /> PEnALnEs,ENFORCEMENT CHARGES and/or HocRLYCHARCEv associated with this operation will be billed to me at the address identified above as the ACCOUNTAnnItE.cy for this site. I also certify that all <br /> 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 /> 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 <br /> 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 <br /> provided to me or my representative. IN!T i <br /> 1 <br /> PLEASE PRINT I ! 1 L <br /> APPLICANT NAMEp I _t 1 m hu�OV I L SIG NATU <br /> TITLE NCI5 e r (PHOTOCOPY REQUI <br /> ! I I URED) <br /> Approved By Date Accounting Office Processing Completed B- Date <br />