Laserfiche WebLink
San Ju.quin County Environmental Healtr ,partment GREEN FORM <br /> DATE MASTER FILL RECORD INFORMATION "MFR" &C) S� <br /> OWNER ID# <br /> f� CASE# UNIT IV <br /> gtiencn eRFec FnR FHn n�F nNiv VV �� <br /> vV OWNER FILE <br /> CHECKIF OWNER CURRENTLY ONFILE WIfH EHD <br /> COMPLETE THE FOLLOWING PROPERTY OWNERINFORMATION; <br /> PROPERTY OWNER NAME ��.(Z�� <br /> LA`W'�7 2-( PHONE <br /> First MI Last <br /> SOC SEC/TAx ID# <br /> BUSINESS NAME NA 0,,%l,t �_ <br /> DRIVER'S LICENSE# <br /> Owner Home Address I ri l 5 <br /> STATE C/4 �7,iPQ 42 <br /> City LQ 1 <br /> Owner Mailing Address <br /> State Zip <br /> Mailing Address City <br /> TYDF nF OWNFRGMTD OTHER❑ <br /> CORPORATION❑ <br /> INDIVIDUAL <br /> PARTNERSHIP❑ FED AGENCY❑ <br /> FACILITY FILE <br /> D O h'1 v JFCROSS Rt F ID# <br /> ACCOUNT ID# <br /> FACILM I # INv# <br /> MP E HE WI rNFVR <br /> Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ No ❑ <br /> Is this an E)aSTING Business LOCATION but a NEw TYPE of regulated Business? <br /> YES ❑ No ❑ <br /> BUSINESS/FACILITY/SITE NAME � /— <br /> A-t) <br /> S1j3TE# BUSINESS PHONE <br /> SITE ADDRESS <br /> Y+ STATE ZIP <br /> CITY <br /> BOARD OF SUPERVISOR DISTRICT LOCATION CODE <br /> KEY1 Ker2 <br /> ===� — -==�7 <br /> Attention:or Care Of(optional) <br /> Mailing Address/foIFFERENTfiom Fad/ityAddress <br /> STATE ZIP <br /> Mailing Address City <br /> KCCODE <br /> APN# COMMENT: <br /> HIRD PARTY BILLING INFO: Complete if Billing Party is different from Property Owner or Facility Operator identified above. <br /> (/ Attention:orCare Of (optional) <br /> BUSINESS NAME I un ^/11 <br /> J O�, PHONE /4–F5 53 <br /> FMailing Address ( 7_ v L <br /> l �/ STATE z'P <br /> C <br /> m J <br /> d rrn�uvr d nnacct <br /> for fees and charges OWNER FACILITY/BUSINESS '"'THIRD PARTY BILLING <br /> Ili i i�r atin(nntP�i Nw A(KNOWI FncmeNT: I,the undersigned Applicant,certify that I am the Owner,Operator,or Authorized Agent of this Business,and I acknow at all PE2titIT FE <br /> ntified above as the dCCQL,) 40Ut7FlS for this site. I also certify tI <br /> PEv tt771 s,EAFOHCEMENT CHARGES and/or Hot�YC/[nitcl.s associated with this operation will be billed to me at the address ide <br /> located at the above facilitylsite address,I hereby authorize the release <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 an <br /> Standards and STATE and/or FEDERAL Laws and Regulations. As the undersigned owner,operator,or, agent of the property sou as it is available and at the same time i <br /> y any and all results and environmental assessment information to SAN JOAQUIN COUNTY ENVIRON'fENIAL HEALT <br /> H DEPARTMENT v <br /> provided to me or my representative. / PLEASE PRINT SIGNATURE <br /> APPLICANT NAME �G GQ Cao lO✓ <br /> ?4/ <br /> DRIVER'S LICENSE# 9 7 <br /> TITLEG Q ,1 (PHOTOCOPY REOUIRED) ` <br /> Accounting Office Processing Completed BY <br /> t.L_ DateI L4 <br /> Approved BY Date 0 <br />