Laserfiche WebLink
San Joaquin County "ublic Health Services Environmen ' Health Division <br /> 0t �— GREEN FORM <br /> Z <br /> s <br /> ✓DATE MASTER FILE RECORD INFORMATION "MFR" <br /> SHADED AREAS FOR EHD USE ONLY OWNER ID# /''I!'.+f(J ` CEASE# UNIT IV <br /> OWNER FILE <br /> COMPLETETHEFOLLOW/NG PROPERTY OWNER INFORMATION.- CHEcKIF OWNER CURRENTLYON FILE WTHEHD <br /> PROPERTY OWNER �� PHONE <br /> NAME �`�� �• ✓ r/ <br /> First M/ last <br /> BUSINESS NAME CIA l)rl/2�.�( v / z Q� /'± �� Q60 l2{�/ILS r .��!/.F5, $ C SEC I TAX I D# <br /> �l�/Nl.�/� CJI L�/ l� �/ G E t/Lr✓!1; OLd <br /> Owner Home Address I!l A DRIVER'S LICENSE# <br /> city STATE ZIP <br /> Owner Mailing Address F0 ftX025 <br /> VV Gf 1�Zc�t D2i10o Tiplrf" <br /> Mailing Address City Sa� �rf1n StateCA <br /> zlp445F 3-0:7 2 5 <br /> CORPORATION IJ INDIVIDUAL❑ PARTNERSHIP❑ FED AGENCY❑ OTHER❑ <br /> ry L,�» FACILITY FILE <br /> FACILITY ID# G/ f�!✓r'y I CROSS REF ID# ACCOUNT ID# INV# <br /> COMPLETETHEFOLLOW/NG BUSINESS/FACILITY/SITE INFORMATION.- M-1IS this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DIVISION? YES E] No M <br /> Is this an EXISTING Business LOCATION but a NEW TYPE of regulated Business? YES ❑ No 2 <br /> BUSINESS/FACILITY/SITE NAME ^l__vo�� � �'` t � IPCID VII aLa � (otf) w <br /> /\./"l�,/►`(C)� 111 .y`/N1/ Il 11��/cYl r �—T_ Vh-I—Y.IJ_� 1 r <br /> SITE ADDRESS SUITE# BUSINESS PHONE <br /> f6Do LO. '-)p-echnut <br /> CITY �ST/�T1/"�j E zip <br /> C' <br /> I.BOARD OF SUPERVISOR DISTRICT I ( LOCATION CODE I ,�';i Yh'4: ,. _,z:.„. ., (. KEY2 [ <br /> Mailing Address ifD/FFEREN'rfrom Faci/ityAddress Attention:or Care Of(option/,) <br /> Mailing Address City STATE ZIP <br /> SIC CODE APN# COMMENT: <br /> THIRD PARTY BILLING INFO: Complete if Billing Party is different from Property Owner or Facility Operator identified above. <br /> BUSINESS NAME ,•1 Attention:orCare Of (option/) <br /> ron y r / Nlana u MADVIC <br /> Mailing Address ( � j botbn er C1j,,s Rvo © oa bw Of1I J PHONE �3`qt Lc4 J <br /> CITY S �a� fM t 1 l\ lVW G► TATE zip ��✓V T <br /> ACCOUNTADDREss for fees and Charges OWNER FACILITY/BUSINESS THIRD PARTY BILLING <br /> BILLING AND COMPLIANCE ACKNOWLEDGMENT: 1,the undersigned Applicant,certify that 1 am the Owner,Operator,or Authorized Agent of this Business,and I acknowledge that all PERMIT FEES, <br /> PENALTIES,EvFoxcEMENTCIIARGES and/or HouRLY CHARGES associated with this operation will be billed to me at the address identified above as the ACCOUNTADDRF.SS for this site. 1 also certify that all <br /> 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 FEDERAI.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 DIVISION as sooAas* available and at the same time it is provided to <br /> me or my representative. <br /> PLEASE PRINT <br /> APPLICANT NAME VOWr M 1ilaI©V IC.t'L SIGNATURE <br /> DRIVER'S L/lc;ervSE# <br /> TITLE ,eI �►ne- ?IC'Ci'ul� Mdoaar' DRIVER'S LI EQUIR ED) <br /> Approved By Date Accounting Office Processing Completed By Date <br />