Laserfiche WebLink
t San Join County Environmental Health Department RQYM�D <br /> "� L'T 17"� Y MASTER FILE RECORD INFORMATION "MFR" 9 20p1� <br /> euenm eovec cna FHA icc Ax r OWNER ID# CASE# SAN I <br /> 06)UO\S11Ob H E� cC(�/y <br /> OWNER FILE rTVEPARTMEM, <br /> COMPLE7E7NEFOLLOWING PROPERTY OWNER INFORmwyom O21C)r F OWNER CORNENRYONFDEWlDf EHD ❑ <br /> PROPERTY OWNER NAME PH <br /> First MI Lest <br /> BUSINESS NAME bmpmrct / soC SEC/TAX ID# <br /> aj <br /> nellimpaae-ok-7 (Ino <br /> Owner Home Address P.b . RIvEr's Lxcex E# f' <br /> cry V STATE/ A uP v33� <br /> Owner Mailing Address O. IVI <br /> D <br /> Mailing Address City 0 V state Zip 2� <br /> TvnvnrtnuxFoexta J <br /> C(NVORATION� INDIVIDUAL❑ PARTNERSHIP FED AGENCY❑ ODfFA❑ <br /> FACILITY FILE <br /> FAQLmI p y CRGss REFID# ACCOUNTIDAl O INv# <br /> COMPLEIF 7NEFOLLOWING BUSINESS I FACILITY I SITE rNFORMA77 N' <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/FACULTY/Sm NAME <br /> SHE ADDRESS MID SURE# BUSWESSSPWNE <br /> cm STATAA 111P ` /�3 J <br /> O <br /> BOARo oFSwERVIson DlsnRxCr LorwTtIINCOOE KEY, KEY2 <br /> Mailing Address ifDIFFERENTfrom Fao7iWA14i eu Attention:or Care Of(optional) <br /> Mailing Address City STATE ZIP <br /> SIC CODE APN# COMMENT: <br /> THIRD PARTY BILLING INFO: Complete if Billing Party is differentfrom Property Owner oTFacility Operator identlfled above. <br /> Rumess NAME Attention:CrCare Of (Opf onal) <br /> Mailing Add,;; 95 -(' PHOrg /�,f� <br /> Cm ')an ,I� STATE /1 R �95- /'�]&Ci� <br /> 'for fees and Charges OWNER FACILITYIBUSINESS l/ THIRD PARTY BILLING <br /> an t mr,♦Nn Cow,ours'ACE NOWT EDGMENT; I,the tmdersigned Applicant,certify that I..the Owner,oarraloq ov Authodud Agem of this nosiness,and t aelmowledge that all PE2MFPEES, <br /> PENd om,ENFOR AT-CHARLES and/or ROOmYCH Ev associated with this operatian will be billed to me at the address identified above As the 4(K=4DDMCe for this site, 1 also cartify Mat <br /> all information provided on this application is true and correct,and that ail regulated activities will be performed in accordance with all applicable SAN JOAQurN COSMn`V Ordinance Codes and/or <br /> Standards and STATR and/or FEDERAL Laws and Regulations. As the und..igped owner,operator,or agent of the property lorated at the above facility/site address.I hereby authorize the release of <br /> any and all resuls and environmental assessment informstion to SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon'as it <br /> iis'available <br /> �and at the same time it is <br /> Provided tonor or <br /> NAME G�/ Teat representative. <br /> APPLICANT NPPppD /I CJGE�'✓Y I[N6Y <br /> SIGNATURE If�rl L1LI tr�JJ <br /> TIRE DRIVER'S LICE # <br /> I -10T000PY REOU D) ,t <br /> MProP ^I 9.ed By Date I A¢ausshs9 Office Processing Completed BY Dane ` -? <br /> 29-02-002 April 25,2003 <br />