Laserfiche WebLink
San Joaquin County �?ublir_Fiealth Services EAtk141Wllo <br /> GREEN FORM <br /> DlA I MAER FILE RECORD INFORMATION FR" K/ t� qq-) <br /> :. <br /> UNIT <br /> VI <br /> PHADEgAaES4 FOREtt043E0afY f+ k iRIDIf.1 '41} > YI F�,IA#E�,55�yIS �P!$3e ,y as �� a\IT IV <br /> T OWNER FILE <br /> COMPLETE THEFOLLOW/NG PROPERTY OWNER INFORMATION.' GNECK Ir OWNER CuReENavoN vile wirNEHD <br /> wJic � L �1-T iC <br /> PROPERTY J 4 PHONE I <br /> OWNER NAME � I'f 1' Y o ct - O "- 33 <br /> 3 <br /> `Flu MI lest <br /> BUSINESS NAME �\IOMS SOC SEC/TA%ID# <br /> Owner Home Address 4 `� DRIVER'S LICENSE# <br /> City ^ (((^^^STATE ZIP <br /> Owner Mailing Address f- .fy 4 7 _ <br /> Mailing Address City / , ,�1 I t State Zip <br /> CORPORATION INDIVIDUAL D PARTNERSHIP❑ FED AGENCY❑ OTHER❑ <br /> FACILITY FILE <br /> -k FAcHui 4D <br /> COMPLETETHEFOLLOW/NG BUSINESS I FACILITY I SITE INFORMATION., <br /> Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DIVISION? YES NOV—] <br /> Is this an E%ISTING Business LOCATION but a NEW TYPE of regulated Business Y YES NO <br /> BUSINEss/FACILITY/SITE NAME '1 <br /> Tj� PA j R-I C,1,4,/� a /M eS <br /> SITE ADDRESS I f - / 1 ^�j I I I/ aNJ 9,1 <br /> I SUITE# BUSINESS PHONE <br /> CITY 1 /v /l. 11�1[CvvC� �[<� STATE ZIP <br /> E � <br /> _13 ARDOFSUPERV18tiR ;_. ._....I_�.+Od1T10N CODE„L.�.�.'s...._.:) K�'7_ :�......,......_�_....,wu xva. '. . 'vc':,�s..K.W—..�-.S�M«....x,.�,1._ <br /> Mailing Address/fD/FFERENT rrom Faol/ilyAddress Attention:or Care Of(optional) <br /> Mailing Address City y�/t D D C4 STATE <br /> IJMM:- r II a 1 T 1 'r <br /> �SICCODE ' - <br /> APN# , , i COEn � . •tt,a� _„� ),",wl.=^', <br /> THIRD PARTY BILLING INFO: Complete if Billing Party is different from Property Owner orFaclllty Operator tdenbrred above. <br /> BUSINESS NAME Attention:orCare Of (optional) <br /> Mailing Address PHONE <br /> CITY STATE ZIP <br /> ADG4UNTADDREBs for fees and charges OWNER FACILITY/BUSINESS THIRD PARTY BILLING <br /> BII.I.ING ANI)CONIPI,IANC3:ACKNOW I.EDCNIENI': 1,the undersigned Applicant,certify that 1 am the Owner,Operator,or Authorized Agent of this Business,and 1 acknowledge that all <br /> PERMIT FFF_f,PENALTIEI',ENFORC'EMENTOMROEY and/or H0URLYCIIARGFV associated with this operation will he billed tome at the address identified above as the ACCOUNTADDREYY <br /> for this Site. I also certify that all information provided on this application is true and correct;And that all regulated activities will be performed in accordance with all applicable SAN <br /> JOAQUIN COUNTY Ordinance Codes and/Or.Standards and.STATE and/or FEDERAL IAm and Regulations. As the undersigned owner,operator,or agent of the property located at the <br /> .above facility/site address, I hereby authorize the release of any and all results and environmental assessment information to SAN JOAQOIN COUNTY ENVIRONMENTAL. <br /> HEALTH DIVISION as soon as it is available and at the same time it is provided to me or illy representative. <br /> I <br /> PLEASE PRINT <br /> APPLICANT NAME 14—/IrZLWA jIC/< S SIGNATURE <br /> ZZ <br /> DRIVER'S LICENS6# <br /> TITLE IaunrnnnoY RmulRFnl <br /> Approved By Dots -Acoounlin OfRoeProobaslnDQomPle�ed �* .3 )AIX, _Osla":?� <br /> �. . <br />