Laserfiche WebLink
San Joaquin County Environmental Health Department <br /> DATE lFj <br /> uly 2, 2010 MASTER FILE RECORD INFORMATION "MFR" GREEN FORM <br /> SHADED AREAS FOR EHO USE Om.Y OWNER ID# CASE# UNIT IY <br /> V !0l ( � <br /> OWNER <br /> FILE <br /> COMPLETE THEFOLLOWING PROPERTY OWNER INFORMATION.' CHECK IF OWNER GuRRENTLr oa F1LE lvw1 EH o <br /> i <br /> PROPERTY OWNER NAME Matt Sanders PHONE 540-966-5315 <br /> First tdl Last <br /> BUSINESS NAME Metalsa SOC SEC/TAX ID# <br /> Owner Home Address 1550 Industrial Drive DRNER'sLICENSE# <br /> city Stockton STATE CA ZIP 95206 <br /> Ownor Mailing Addroea <br /> 1550 Industrial Drive <br /> Mailing Address City Stockton state CA ZIP 95206 <br /> T111 OF 011111115111P <br /> CORPORATION® INDIVIDUAL❑ PARTNEnSI-IIP❑ FED AOCNCY❑ OTHER U <br /> FACILITY FILE <br /> FAOILITY ID# p2'04.30 CROSS REF ID# I ACCOUNT ID Ai)_03�:/_ 1NV# <br /> COMPLETETNEFOLLOWING BUSINESS/FACILITY/SITE INFORhfAT/ON.' /1VY/�1 DIY <br /> Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPT.? YES ❑ No <br /> Is this an EXISTING Business LOCATION but a NEW TYPE of regulated Business? YES ❑ No <br /> E1uswEWFACILRI'/SITENAMC Metalsa <br /> SITEADDRESS 1550 Industrial Drive SUITE# BUSINESS PHONE <br /> Cm Stockton STATE CA Zip 90206 <br /> BOARD OF SUPERVISOR DISTRIOT Z LOCATION CODE 10, EKEY2 <br /> Melling Address ifD/FFERENrfrom FaclldyAddress Attention:or Care Of(apUona/) <br /> Mailing Address City -7 <br /> STATE zip <br /> SIC CODE �PN# / / 7-q o D S COMMENT; <br /> THIRD PARTY BILLING INFO: Complete tdBilling Party is difierentfrom Property Owner orFacility Operator identified above. <br /> BUSINESS NAME Attention:orCare Of(optional) <br /> ENVIRON International Corporation I mei Q u.e2adQ <br /> Mailing AddrOSS 707 Wilshire Boulevard, Suite 4950 PHONE 213-943-6300 <br /> CITY Los Angeles STATE CA Zip 90017 <br /> AccouNTAooREss for fees and charges OWNER FACILITY/BUSINESS HIRD PARTY BILLING <br /> RI1.IxNC.1\11 COan't.In NCE A.C9CNOR'l.EOCt.Imr: 1,the undersi.ned ApplicrosL certify Ilial loin the On•Rer,Operator,or Auth nricrs/:Igent ur thii Ruiines.,and I ncknusrlctigc Ilial nil .7011(/�ELs, <br /> E.vl'fq(L'hslf.Sit'Clat RrlE.1':m d/nr HIIURt.t'L7GU(cL'd'assncin tell with This operation❑gill be billed In ase al the address identi reed sbnve ns I11e:11e[00h7:InOhES3 for this it,. I nils rerti fi Ihut <br /> all iurornsnliun provided oil(his oppilcatian Is Ince:md cm'rert;and Ihai nil reaulnled activities will he perrnnned in accurJunce kids all Replicable SAN JO.IQUIN COUNT)'Ordinance Codes and/ur <br /> Standards anti SrA'r F.mul/or FEDFHAL Lmva and Rcguludow. As the undersigned owner,uperator,or ipent or Ilse property loculcd al the ubovc facility/site address,I hereby msthorize the release of <br /> illy and nll resulli nod cnviroonienini nsscssnunt infornsnlion to SAN JOAQUIN COUNTY L•'N'kARON,\IE,YTAI,IIL1L'1'II DEPARTAIEN r os soon as it is available and ill the same tittle it is <br /> provided to ase or illy I cpresatsnlive. <br /> APPLICANT NAME PLEASE PRINT SIGNATURE_/41 t <br /> Alma Quezada `` <br /> TITLE Associate DRIVER'SLICENSE# A8490774 . <br /> T 0 YRE UIRED <br /> Approvod By !—Lr— onto -7/Wer) 11 Ac.ciontlnq 011lots Proeo-Ing Completed By Dorn <br /> v <br /> 29-02 I0,12,07 (ASTER FILE RUUORD-OlLiil?N <br /> C( L <br />