Laserfiche WebLink
12/20/2006 14:02 FAX U002 <br /> San Joaquin County Environmental Health Department <br /> GREEN FORM <br /> DATE �2�ZO�aG MASTER FILE RECORD INFORMATION "MFR" <br /> c Aa a EH❑ n OWNER ID# T`--� <br /> CASE# UNIT IV <br /> OWNER FILE <br /> COMPLETE THE MILOWINGPROPERTY <br /> /OWNER INFORMATION: OiEtKIF OWNER CVRRENTLYONFILEwrTN EHD <br /> PROPERTY OWNER NAME A/ PMONC �f � <br /> •9S6 • p.7(, <br /> First MI Last ( ✓V <br /> BVSINNAME v Sm SEc/TAx ID# <br /> owner Home Address DRIVER'S LICENSE# <br /> city !, D STATE ZIP <br /> Owner Mailing Address 12'1p /'0 / �yt,� Blvd 5uir <br /> No <br /> Mailing Address City `Vv d State Zip yam/ �p <br /> TIOG AF OMMEIS M J b <br /> CORPORATION INDMDUAL❑ PARTNERSHIP❑ FED AGENCY❑ OTHER❑ <br /> FACILITY FILE <br /> FAcarrr ID# <br /> FOtoss REF ID It j ACCOUNT ID# INV# <br /> COMPLETE THE FOLLOWrNG BUSINESS I FACILITY I SITE INFORNATTON.' <br /> IS this a NEW Business LocATIoN not prevlousty regulated by the ENVIRONMENTAL HEALTH DEPARTMENT. YES ❑ No x <br /> Is this an E)asTING Business LOCATION but a NEW TYPE of regulated Business? Yes ❑ No • <br /> BUSINESS/FACILITY/SITE NAME f G; <br /> SITE ADDRESS 04,if G r 1,4` SUITE# BUSINESS PHONE <br /> CITY ,AA` SKATE ZIP A f O <br /> BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEY1 KEY2 7 3 <br /> Mailing Address if DIFFERENT from Faei/ityAddress Attention:or Care Of(optional) <br /> Mailing Address City wn 1 STATE ZIP <br /> SIC CODE APN# �f JO/ D/ / COMMENT; <br /> THIRD PARTY BILLING INFO: Complete if Billing Party is different from Property Owner or Facility Operator identified above. <br /> BUSINESS NAMEAttention:orCa Of (. No <br /> '/ na/) <br /> wa.t IIGL" I�.IA 4- Si-oel. C-, SGo <br /> [Mailing Address-3//1O &.A"' F PHO rZo <br /> 23 q—? 7 2- <br /> CITY <br /> CITY I O oke yr, STATE CA ZIP q,,2 ,., <br /> for fees and charges OWNER FACILITY/BUSINESS THIRD PARTY BILLING <br /> RifI.ING AND COMPt.LANCE ACKNOw't.EncnT➢NT: 1,the undersigned Applicant,certify that I am the Owner,Operator,or Authorized Agent of this Business,and I acknoN'ledge that all PHRMrT FEES, <br /> PEN'ALTIEY,ENFORcEmENTCNARGES and/or 110URLYCnARGES associated with this operation will be billed to me at the address identified above as the ACCOUNTADDREce 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 /> 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,I 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 c ame time it is <br /> provided to me or my representative. <br /> � PLEASE PRINT <br /> APPLICANT NAME N=ro ST2o„iG SIGNATURE <br /> a�.4 <br /> TITLE `l DRIVER'S LICENSE# <br /> r N� `„�2c34G�GbLa�'S� (PHOTOCOPY REQUIRED) �1 <br /> Approved By Date Accounting Office Processing Completed By ,/ice Date L> (] <br /> 29-02-002 April 25,2003 <br />