Laserfiche WebLink
San Joaquin County Environmental Health Department GREEN FORM <br /> DATE 6 ( D MASTER FILE RECORD INFORMATION "MFRr` <br /> UNIT IV <br /> OWNER FILE <br /> CHgcxff OWNER LLHHeNnYaYFaetvJrH EHD ❑ <br /> A/pLE7E7NEFO2LO*TFGP P INFORMA7I0N: PHONE g- 3 r Z G s <br /> PRQPfJfrYDNNE1fNANE LLQ <br /> Rrst M/ Lest <br /> SOCSEC Taxi # <br /> BUSTtlE55 NAME <br /> OvV rHtwne Address ��. Da2vea'SLffil5E# <br /> CRY SrATe >� N A- <br /> Dwner Mailhrp Address - D B=Md I V <br /> Nailing Address City e <br /> C(XxPCSAn El Fw AOEHcv❑ or„m❑ <br /> p2FACILITY FILE <br /> A �7 <br /> FAtnJn ID# Ooi/DO% RES ID.# ACCt)U TID# <br /> ESS- <br /> Is tris a NEW Business `Law('TION not previously regulated M the ENVDIONMENTAL HEALTH DEPARTMENT} YES ❑ No <br /> Is this an EIOSTDIG Business LOCATION but a NEW TYPE pf regulated Business;? yea ❑ No <br /> Busa+E$JFAtaEry/SnE NANe J/-} —e l� �/P�AlI Ss-S <br /> SneAooncs / L C , TAYTP y �//� �(�j v ��l /�S' scare# eumfesPHorE <br /> CITY7�.7C�� �D�I sr% ZIP dS— <br /> E,,,,, rSuPEaNU0RDaTR LMI-mNCOM V"i K"2 <br /> Na9it*Address fDIFIWReVrfhRn FiadW pO r/�`/Z. 7(��( ALtoMWn:ew Care Of(oy06rsaf) <br /> Matling AddresCRy l� >C�( V sfA,E aP 3 Rz Z <br /> sic CADS o - r tea.M, <br /> THIRD PARTY BILLING INPDr Complete if Billing Party is diferentfiam Property owner OI Facility Operator identified above. <br /> Buseeess NAME 4 1 S 14 <br /> so c , ANantion:a Care Of (OPSEnM <br /> Mailing Address -r (; o J� 2 <br /> STATE Ian <br /> Qty T Y <br /> AGOMMMAGamwfarfeesand eharges yarnER FACRRyIBusiNE HRDPARTY BiLLMC <br /> R r - Arwvewr vrcvmxr: L ae undenipud Applicant.certify time I am the 0,eo,,OPoaMrl or -ted Agmf ofthis Busiueµand I oclm Wilt est oil PExefl'FPEs� <br /> P1INALTIE%ENPQACHMPNTCfL ,M aod/ar HWMTCH.r6Esauoc led with rbc operation will be baled b me al the addreav idebddcd above o dmdGG'Ql1HLdggBGSS for dib ate. I also certify that <br /> 217 ioPo,,nioo Provided on IhL applicedon is ave and re r"I;and tlml aB regulated activities wig be performed It aarordenck with an applicable SAH JOAQM COQHIY Ordinance Coden and/or <br /> Snndaeds god SrATE and/or 6718 Lswe and Reguiawm As the under aped anon,opme r,or agent of Ibe Property I."et the above fadlitylate addrmv.7 hereby tuthorirt the rekase of <br /> any and 0 resulta and roviro®enW areenuaat information to SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon u it is available and at the same time it is <br /> provided to me or my represeo/tive. PRIIar v JP <br /> 1J <br /> APPLICANT NAME ('.J �-sSC Cf(.l{ e S SIGNATURE <br /> TITLE .,`P . D DEQ NlN Eo; <1s -2- <br /> Apprortl 6Y V DNe A¢ouetlnp t511be Ptpprbg Cmr9leDadar Dae. <br /> 2962-002 Apri125,2003 <br />