Laserfiche WebLink
San juaquin County Environmental Health uepartment <br /> GREEN FORM <br /> DATE �2 20��2, MASTER FILE RECORD INFORMATION "MFR" _)LG 2 3 2002 <br /> OWNER ID# --FCASE# <br /> UNIT I <br /> OWNER FILE <br /> COMPLETE THE FOLLOWING PROPERTY OWNER INFORMATION. CHECKIF OWNER CuRR&vnroNFILE wrrHEHD <br /> PROPERTY OWNER PHONE,,,,, <br /> NAME <br /> r""first �!� lest <br /> BUSINESS NAME � � �,'f/f�� � � /SC� SOC SEC/TAx ID# <br /> Owner Home Address /�(�Jl' V 1// Il l/ DRIVER'S LICENSE# <br /> City STATE ZIP <br /> Owner Mailing Address [, n // /� <br /> Mailing Address City C AA/�/,n I / /�I ry-) �l State � F�i <br /> P //I L <br /> TYPF OF nwNFRGHTD Jl.��f i l ICC��C�t. _ f <br /> rnR MDATTr1N TNr1TVTn—, I I DARTNFDGHTD 1-1 r—A('FNr'V I nTHFD 1 1 <br /> FACILITY ID# CROSS REF ID# ACCOUNT ID# INV# <br /> COMPLETE THEFOLLOWING BUSINESS I FACILITY I SITE INFoRmATIoN., <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/FAaLrry/SITE NAME j ^, —� I � <br /> IM <br /> SITE ADDRESS �SUITEEj#/^C�I BU IES�S,PHPH1O�NE <br /> gs� � <br /> ' f I <br /> 3E) - �C� <br /> Cm STATE ZIP <br /> BOARD OF SUPER✓✓✓VISOR DISTRICT I LOCATION CODE I I KEYl I KEYZ I II <br /> Mailing Address if DIFFERENT from Facility A ddress Attention:or Care Of(optional) <br /> Mailing Address City STATE ZIP <br /> MI. <br /> SIC CODE APN# COMMENT: <br /> THIRD PARTY BILLING INFO: Complete if Billing Party is differentfrom Property Owner or Facility Operator identifiedabove. <br /> BUSINESS NAME �X. Attenti jor Care Of (optional) C- '�-ry� <br /> Mailing Address I I e4 I ^ �� I^ r I nD PHONE LLO <br /> Cm P�.�ck)0 l �l) n,V-a--, <br /> v61�TC� STATE 6�q ZIP � YI I I <br /> T AV <br /> Arr0UNLWZiS for fees and charges OWNER FACILITY/BUSINESS THIRD PARTY BILLING 1 .-( <br /> Rn.t i�[::5vo t'O\1PLLWt'F'.A['hN05ci t nGSit st: 1,the undersigned Applicant,certify that I am the Ox•ner,Operator,or:lttlkoriced.dgent of this Business,and 1 acknowledge that all PER.VIT I�EE'S, <br /> PENAL7/E.5',ENFORc'EMENI'CHARGE.S and/or IIOURL YCHARGES associated with this operation will be billed to me at the address identified above as the AcCOUNTAnnRF.cc for this site. 1 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,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 itis <br /> provided to me or my representative. <br /> PLEASE PRINT <br /> APPLICANT NAME ?�10J�1 G-�rD=be V) 4 S SIGNATU <br /> TITLE S � ' �t DRIVER'S LICE SE# <br /> (PHOTOCOPY REO <br /> Approved By Date Accounting Office Processing Completed By Date <br />