Laserfiche WebLink
R <br /> Se'---"aquin County Environmental Hear--'*-lepartmert <br /> `••—„s 1 GREEN FORM <br /> DATE �L�,�Z O MASTER FILE RECORD INFORMATION "P FR""' <br /> „�P�Q_9Rf,AS FQ$ H�VSFi nLY OWNER ID# � r V iE Ye V NIT IV <br /> OWNER FILE <br /> • n CHECKIF OWNERCURRENnYONFrtewrrHEHD (� <br /> COMPLETE THE FOLLO WING PRO P ERTY OWNER INFORMA770N: l6°I/I ?n .,) E <br /> PROPERTY OWNER [ZI ONE <br /> NAME /. <br /> �ACZ9 9 I �cl q q& 4� 7S <br /> t' <br /> I <br /> Feat MI last <br /> BusrNEss NAME Soc SEC J TAx ID# <br /> c� �.�� <br /> Owner Home Address € DRIVER'S LICENSE# <br /> � <br /> ! <br /> City f.- 7y-A-1 <br /> I STA Tti lA ZIP <br /> Owner Mailing Address <br /> Mailing Address City State Zip <br /> TYPE OF OWNERSHIP <br /> CORPORATION C INDIVIDUAL AL PARTNERSHIP❑ FED AGENCY❑ OTHER C <br /> FACILITY FILE <br /> FACILITY ID#. � i .':� ,.�; CROSS REF ID# A6COUNT TD`# ..+ <br /> INV'# <br /> CCMPLETETHEFOLLOWUG BUSINESS/ FACILITY f SITE INFORMATION: <br /> is this a NEW Business LocATioN not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES C No <br /> Is this an EXISTING Business Loc ATION but a NEW TYPE Of regulated Business? YES C No <br /> BUSINESS/FAcnm/SITE NAME <br /> L KPO <br /> SITE ADDRESS SUITE# BUSINESS PHONE <br /> cTr, STC I 74111 j, -P-A- <br /> ( T ! 4S 2L S— <br /> Bo.RD of Ska ERvrsoR DIsmcr I l LOCATION CODE KEYl ! KFY2 1 !I <br /> Mailing Address if DIFFERENT hom FacilityAddress L Attention:or Care Of(optional) <br /> Mailing Address City STATE ZIP <br /> SIC CODE —�_ APN# <br /> JJ l t f <br /> THIRD PARTY BILLING INFO: Complete if Billing Party is different from Property Owner or Facility Operator identified above. <br /> BUSINESS NAME Attention:orCare Of (optional) <br /> Mailing Address PHONE <br /> CITY STATE ZIP <br /> ACCOUNT ADDRESS for fees and Charges OWNER FACILITY/BUSINESS THIRD PARTY BILLING <br /> BILLING AND COMPLIANCE ACKNOWLEDGMENT: I,the undersl can -ify that I am the Owner,Operator,or Authorized Agent of this Business,and I acknowledge that all PERMIT FI:Es, <br /> PENAL77ES,ENFORCEMENTCHdRGE4 and/or HouRLYCHARGE4 associated with this operation will be billed to me at the address identified above as theACCOUNTADDRE4Y 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 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,I 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 it is <br /> provided to me or my rep r e. <br /> PLEASE PRINT <br /> PLICANT NAME 1. (, �1 SIGNATURES <br /> TITLE 1 A A (PHO O OPY REQUIRED) <br /> Approved By Date -= Accounting Office Processing Completed By ! Date <br />