Laserfiche WebLink
San Joaquin County Environmental Health Department <br /> GREEN FORM <br /> DATE 8_ �2 - MASTER FILE RECORD INFORMATION "MFR" <br /> SHenrn eRF c FO <br /> • R FHA ucF ttNly DWNERID# CASE# UNIT IV <br /> OWNER FILE <br /> CHECXIF OWNER CURRENTLYON FILE WITH E H D ❑ <br /> Co MPL ETE THE FOL L 0 WING P R 0 P E RTY OWNER INFORMATION; <br /> PROPERTY OWNER NAME e 11r� PHONE — Q /� <br /> First MI l Lastt ) �7 V <br /> BUSINESS NAME SOC SEC/TAX ID# <br /> Owner Home Address r C4 DRIVER'S LICENSE At <br /> city STATE ZIP G <br /> Owner Mailing Address <br /> `juM� u <br /> Zlp <br /> Mailing Address City State� � �,� �( J� _ <br /> TYPE nF OwNFRCHTD �J <br /> CORPORATION❑ INDWIDUAL,14 PARTNERSHIP❑ FED AGENCY❑ OTHER❑ <br /> /FACILITY FILE <br /> ISI FACILITY ID# CROSS REF ID# (t Il " ACCOUNT ID# I' INV# <br /> COMPLETE THE FOLL WING BUSINESS I FACILITY SITE INFORMAZT01W <br /> Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ No Rr <br /> Is this an EIaSTING Business LOCATION but a NEW TYPE Of regulated Business? n YES ❑ No, <br /> BusENEss/FAcILrrY/SrrE NAME �a r <br /> SITE ADDRESS SUITE# BUSINESS PHONE <br /> CITY �Q r ( STAT /I ZIP <br /> BOARD OF SUPERVISOR DISTRICT LOCATION CODE I KEYS Kt:YZ <br /> i <br /> Mailing Address ifDIFFERENTfrom Faci/ityAddress Attention:or Care Of(optional) <br /> Mailing Address City J STATE ZIP <br /> SIC CODE EPN# 2 2-3 --/53 _ J COMMENT: <br /> THIRD PARTY BILLING INFO- Compieteif Billing Party is different from Property Owner or Facility Operator identified above. <br /> BUSINESS NAME AlUn 4 4tv — �Vifvn m mia Attention:orCare Of (optional) <br /> Mailing Address "� PHONE �t f (J;`lJ/'�1 <br /> CITY � �_I ,� �` � STATE ZIP <br /> ACCQU&T ADDAUS for fees and charges OWNER FACILITY/BUSINESS `• 1 THIRD PAR/TY BILLI/N� <br /> $ILLtNG ANn fYIMPLIANCF ACKNOWLEDGMENT: 1,the undersigned.Applicant,certify that I am the Onwer,Operator,or Authorized Agent of this Business,and I acGowl ge that all PFRALLT FEES, <br /> PFNALT/EC,FNFnRCF.NFAT CHARGES and/or HOURLY CHARGES associated with this operation will be billed tome at the address identified above as the ACCOUNT.4 nnRF.C.0 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 JOAQURN COUNTY Ordinance Codes and/or <br /> Standards and STATE aud/or FEDERAL Laws and Regulations.As the undersigned owner,operator,or agent of the property located at We above facility/site address,I hereby authorize the release of <br /> any and all results and environmental assessment information to SAM JOAQUIN COUNTY ENVIRONI�NTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my representative. PLEASE PRINT <br /> nn� I <br /> APPLICANT NAME I I m(if1 SIGNATURE <br /> TITLE DRIVER'S LICENSE# <br /> r 5`7((/T .I 6�c'`lJ I (PHOTOCOPY REOUIRED) <br /> APProw�BY Date Accounting Office Processing Completed By Date <br /> 29-02-002 April 25,2003 <br />