Laserfiche WebLink
`w + I. <br /> San Jouin ounty Environmental Health pent <br /> CAIS 0'S 12-CCB MAWE ILE RECORD INFORMATION P` R' GREEN FORM <br /> SNADEOAREAa FOREHD1 ONLY owNER ID# D� D��Cn�Ey CASE# UNIT IV <br /> OWNER FILE <br /> COMPLETE TNEFOLLOww PROPERTY OWNER/NFORMAT/ON' CNEoxor OWNER CURRENf1YONFILEnsw END <br /> PROPERTY OMER NAME PHONE <br /> First MI Last <br /> BUSINEw NANE SHELL. OIL PRnoAX-Tg' US SOCSEC/TAzID# <br /> Owner HOnae Address ZOrt%jS $',WIL}(INGXTON /IVC-. DRNER's LICENSE# <br /> city cARSoN STATE CA ZJP clo810 <br /> Owner Milling Address <br /> Mailing Address City State Zip <br /> Tvo�OF OWN Faa,p <br /> CORPORATIONF] INDIVIDUAL❑ PARTNERSHIP❑ FED AGENCY❑ OMER❑ <br /> FACILITY FILE <br /> FgCILnY ID# F�d� l"t� CROss REF ID# ACc�OD���� INV# \/I <br /> COMPLETETMEFO1LNLOwtNGBUSINESS/FACILITY/SITE INFORMATION: l ,l <br /> Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPT.? YES ❑ No ❑ <br /> Is this an EXISTING Business LOCATION but a NEW TYPE of regulated Business? YEs ❑ No ❑ <br /> BUSINEss/FACILfn'/S1TENAME +f u- OIL ?9L VC.-tS vs: <br /> SREADORESS pil, �I / /1 1 `` SUITE# BUSINEWPHONE 2,7 <br /> Cm rir°t a \ L� v\ V STATE C'4- ZIP cI ox Xn 9 <br /> BOARDOFSUPERVISOR DISTRICT LODATIONCODE KEY1 KEY2 <br /> Mailing Address Y'DIFFERENTfxon,Faci/ityAddress, Attention:or Care Of(OobbosaQ <br /> Mailing Address City STATE ZIP <br /> SIC CODE APN# COMMENT: <br /> THIRD PARTY BILLING INFO: Complete ifBilling Party is different from Property Owner or Facility Operator identiffedabove. <br /> BUSINESS NANE Attention:orCare Of (optional/ <br /> Mailing Address PHONE <br /> CITY STATE ZIP <br /> AammEADORm for fees and chargee OWNER FACILITY/BUSINESS THIRD PARTY BILLING <br /> BILLING AND COMPLIANCE ACKNOWLEDGMENT: 1,the undersigned Applicant,certify that 1 am the Owner,Operator,or AutAoriZed Agent of this Business,and 1 acknowledge that all Pim TT FEES, <br /> PE,wtnEs,ENFoxC &vrQt o;and/or aountvCtutt associated with this operation will be billed tome at the address identified above as the AMOADDR 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 ofthe property located at the above facility/sitjoluddress,I hereby authorize the release of <br /> any and all results and environmental a e formation to SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT it is available and at the same fine it is <br /> providedtomeormyrepresentativ <br /> APPLICANTNAME a5 4 ttif GOi SLtp.G(. PLEASE PRIMTjL1r17`A. I/ SIGNATURE <br /> TITLE ` , / `�' DRIVER'S LICEN <br /> G�d 5 (PHOTOCOPY REQUIRED) pO <br /> Approved By DaW (� AccouMXng Oflke Proneveing Complvbd By Data 60 <br />