Laserfiche WebLink
Jun 01 04 11 : 25a RL-- EM, INC. (909) 476-6819 p• 2 <br /> San Joaquin County Environmental Health Department <br /> b GREEN FORM <br /> °i� `� MASTER FILE RECORD INFORMATION "MFR" <br /> jty,O I•agar FXp�xc nror OWNER ID# p� alz3q� CASE# UNIT IV <br /> OWNER FILE <br /> COMFLE7 c THE FO.LOWING PROPERTY OWNER INFORMATION; OtrcKDF OWNER CVRRrNIIPONPzLEwrrH EHD <br /> PROPS(n C OWER NAM IPHONE �, gy3_�77� <br /> First MI Las! <br /> BUSIN:ss N LAE '66te 'Plza pb2 es Soc SEc/TAx ID# <br /> Owne r F o n e Addres 'O�'1 �1 L� f+' Q DRIVER'S LICENSE# <br /> CityC!}M 'D h SrAre %% ZIP Seo a� <br /> Ownei M ii Ing Addres <br /> / Mailin3Jd f ess City C+ / se to stateC� zip <br /> e<u acute <br /> 31' <br /> r(OPA <br /> -ATTON❑ INDMDUAL❑ PARTNERSHIP'. FED AGEfKY❑ OTHER❑ <br /> FACILITY FILE <br /> FAQLrY:C IS��/ CROSS REF ID# AccouNTID#COMA. <br /> E7:CdEFOftoHqNG IBUSINESS I FAULM SITE IALFogMwTom <br /> Is this a V 1V Busin(ss LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT.> YES ❑ NO <br /> IS this ar I}ISnNG E Jsiness LOCATION but a NEW TYPE of regulated Business? YES ❑ No Lld <br /> BUSINE S)F tam/SR NAME .51CA 4 LU,vIQb/Z MF6ReS <br /> --- 2 <br /> SITE AC DR r i 37� lit/ Amt Zd"L tv/✓ Avb $[1tIE# BUSINESS PHONE 9la 77?1 <br /> Cm" < JOC/G SCJ J STATE C�. ZIP glI S06 <br /> BOARD I W;iL N RVISOR D STRICTv IENCODE I KEY I KEY2 <br /> Mailinf Ai k ass/f DL cF.REA7 rum Fati/ityAd&ieFs Attention:or Care Of(optional) <br /> LMa,1,Cn,A It Ims City STATE ZIP <br /> IE APN# I U 7 f 7 r CAMMENT: <br /> THIRD,2t F TY BILLING INFO: Complete if Billing Party is different from Property Owner or Facility Operator idenbried above. <br /> BUSINES STA II: n^>�L� Attention:OrCare Of(oplYona/) <br /> Mailing <br /> At d iss jfAl�v A I +' C�J � � PstoNE <br /> Clrr —- v l/t t / �SIATE ZIP <br /> for fees and charges OWNER FACILfrY/BUSINESS THIRD PARTY BILLING <br /> M "IPI Ia iCF srKXOw1 PtvaIFNT: ],the undersigned Applicant,certify that 1 am the On"cr,Opemror,or Authorized Agent of th' sines,and 1 acknowledge that nqr Fres, <br /> PIsNA4 rIFS.Er F n CENEA7 C URGES and/or HOGR[r C11ARGFZ associated with this operation will be billed to me at the address identified above as thcA also certify that <br /> all inform,tit,t ,r ovided on this application is true and correct;and that all regulated activities will be performed in accordance with all applicable SAN JOAQUIN COGSTY Ordinance Codes and/or <br /> Standards mt ' r sTE and/o FEDERAL Laws and Regulations.As the undersigned owner•operator,or agent of the property located at the ab" facility/site address,l hereby authorize the release of <br /> any and a) to st lis and env•onmen(al assessment information to SAN JOAQUIN COUNTY ENV)RONMEN"I'AL HEALTH DEPARTMENT soon as ar7211ablc and at the some time it is <br /> provided u In�.r my repres mAtive, <br /> --�' PLEASE PRINT <br /> APPLIC LN r VAME SIGNATURE—�oS <br /> TIYLE DRIVER'S SE# ��]T <br /> (PHOTOCOPY EOUIREDI N ta[ <br /> 9 <br /> Approve[B)= Date Aocounting Deflce Processing completed BY 7177 Date <br /> 29-02-002 A n 125.2003 <br /> CONFIDENTIAL <br />