Laserfiche WebLink
San Joaquin County Environmental Health Department <br /> GREEN FORM <br /> DATE 1 'MASTER FILE RECORD INFORMATION MFR <br /> S1+GnFt)nRFa FAR FHn IICF r1Nl V UNIT IV <br /> OWNER FILE <br /> CHECK IF OWNER CURRENTLYON FILE WlrH EHD ❑ <br /> COMPLETE THE FOLLOWING PROPERTY OWNER INFORMATION; ^ <br /> PROPERTY OWNER NAME 4 ,1T ,y PHONE <br /> First /V MI ,I Last <br /> SOC SEC/TAxID# <br /> BUSINESS NAME <br /> -' DRIVER'S LICENSE# <br /> Owner Home Address <br /> STATE ZIP <br /> City <br /> Owner Mailing Address I / ) UT <br /> Mailing Address City ///V V State Zip 7� <br /> TVDF nF nWNFRCNiP C/!f, <br /> CORPORATION El INDMDUAL9 <br /> PARTNERSHIP❑ FED AGENCY ElOTHER❑ <br /> FACILITY FILE <br /> FA=ID# CROSS REF ID# <br /> ACCOUNT ID# INV# <br /> mPLETE rHEFOLLOWINGRrTE R <br /> MA <br /> Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YESX No ❑ <br /> Is this an EXISTING Business LOCATION but a NEW TYPE Of regulated Business? YES El NO <br /> BUSINESS/FAQLITY/SITE NAME 144 o (i,�— <br /> ESS <br /> C/ 6 / / JeSUITE# PHONE <br /> SITE ADDRESS SATE � zip ;ZM �/v y / 7-3 <br /> Cm (]G2 <br /> � ` <br /> b� <br /> Mailing Address ifDIFFERENTfrom Fad/ityAddress Attention:or Care Of(optional) <br /> STATE ZIP <br /> Mailing Address City <br /> THIRD PARTY BILLING INFO: Comp/eteif Billing Party isdifferent from Property Owner or Facility Operator identifiedabove. <br /> Attention:or Care Of (optbnai) <br /> BUSINESS NAME r-- C Z <br /> 1 > <br /> _ PHONE <br /> Fm <br /> ailing Address it k 1 l2& 4 <br /> ZDo <br /> STATE <br /> i!' <br /> Cm <br /> a�DF«/"for fees and charges OWNER FACILITY/BUSINESS THIRD PARTY BILLING <br /> Ruc "n('ovtrt t wcr `cKvrnvt rn0ate_Nr; 1,the undersigned Applicant,certify that 1 am the Owner,Operator,or Authorized Agent of this Business,and 1 acknowledge that all PER.LfIT FEES, <br /> PENALTIES,ENFORCEVEATCIL4RGFS and/or HOURLY CHARGES associated with this operation will be billed to me at the address identified above as the Acro-vim 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 JOAQl1LN COuvrY 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 ENVIRONNIENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my representative. PLEASE PRINT SIGNATURE t , <br /> APPLICANT NAMEDRIVER'S LI <br /> �`(J/� /�/y� �/ <br /> TITLE r l�..n�/ivfJSv (PHOTOCOPY RECENSE OUIRED) C a CV,14 26 <br /> APP.,,.d By Date Accounting office Processing Completed By <br /> 29-02-002 April 25,2003 13 MIMIT <br />