Laserfiche WebLink
San Joaquin County Environmental Health Department <br /> DATE lJ �-41V/ MASTER FILE RECORD INFORMATION `TMFREF GREEN FORM <br /> cxmmaFFac mF PHn...ErN OWNER IID# GSE# <br /> W _ ._ UNIT <br /> I" <br /> OWNER FILE V V <br /> COMPLE7E 7NEFOLLOWI166 PROPERTY OWN ER INFORMATION.• _C7lt f F OWNER Cf/AREny0NF"Wfrn EHD <br /> PROPERWOWNERNAME <br /> First MI Last <br /> BtISmESS HANE J oL , ��• .v sBBf y/ <br /> / Tr/rAXtD# <br /> OWner Nome Address (� r'T lL 0 DRIVER'S LS0315E <br /> � G /J # <br /> v V STA ECfI <br /> Owner Mailing Address <br /> Mailing Address City State Zip <br /> TTPF K ffwxFa<xm <br /> CoaPauTlOrl INonnoua&❑ PARTNERSHIP FEDAGENCY❑ OTHER El <br /> FACILITY FILE <br /> FAa ID# CRoss REFID.# A=uNi ID# IHv# <br /> COMPLETE THE WI RMA77 <br /> Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YEs ❑ No'9 <br /> Is tho an EXISTING Business LOCATION but a NEw TYPE of regulated Business? YES ❑ N091 <br /> BUSINESS/FA /SnEWINE (/ CC L //--//,-E <br /> SITE AncaESs / of0 1114 /Z//c 0&0 C Sum# Bum+Eu.P E <br /> D <br /> Cm STATE � ✓(J 7 <br /> BOARDDFSUPERVIDDRDrsmlcr CLouTmn Com Keil KEY <br /> Mailing Address if DIFFERENTIrgrn Fad/ityAalamas Attention:or Care Or(optlwva/) <br /> Mailing Address City <br /> STATE 7JP <br /> sic CODE. APN# COHNENr. <br /> r <br /> THIRD PARTY 13ILLING INFO: COMPICte%f Billing Party isdilferentfromProperty Owner orFacilityOperator idenh'fiedabove. <br /> BUSENESS NAME Attention:orCare Of (optdona/) <br /> Mailing Address <br /> PHONE <br /> CITY <br /> STATE '[1P <br /> AA'NDCOanneFcc for fees and Charges OWNER FACILIT'/BUSINESS THIRD PARTY BILLING <br /> Rn r mr.AND('Oa•PI uxry A ^; I,the undersigned Applicant,certify that 1 am the Owner,Operator,or Authorized Agent of this Businas,and 1 acknowledge that all PERuff F$Es, <br /> PENALVIU,EnTnRCEMENTGTAROEs and/or NOURLYCHARGE assoriated with thia operation win be billed to meat theMd.identified above as the AcvnrwrAnnnves for this site. I iso certify that <br /> all information provided on this application is true and correct;and that ESR regulated activities win be performed in accordance with all applicable SAN JOAQUIN Coum Ordinance Coda and/or <br /> Standards and STATE and/or FEDERAL Laws and Reguladom. 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 AM ESB moth and environmental assessment information to SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPAR T As soon At it u available and at the same time it is <br /> provided tome repreeohtive. <br /> N <br /> APPLICANT NAMME U }7E Pa <br /> P.-�I/G Miert /,L /� SIGNATU <br /> i <br /> DRIVERS LICENS # <br /> O/t Cry flmoTomPr urREol <br /> II Approved BY Date Acmuneng Office Procashp Completed BY Date <br /> 29-02-002 April 25,2003 <br />