Laserfiche WebLink
Froro:FARISM & SMALL • 2099520250 09/009 16:06 11993 P.002/00°l <br /> San Joaquin County Environmental Health Department <br /> D ® 11v/Ij�C REEN FORM <br /> DATE 26 August 2009 MASTER FILE RECORD INFORMATI EC <br /> 9f EHOWEo OWNER IDS SEP 0 4 2 09 UNIT IV <br /> OWNER FILE ENVIRO ' L1 <br /> commE/E 7NFFoLwllPROPERTY OWNER INFORMATION: AalevarwvntEWm/Enn <br /> V <br /> YIIOtlE. LV> >]O-,VVV <br /> YROpERryUYMER NAatE <br /> First MI Last <br /> BUSINESSNAME Coramunity Bank of San Joaquin SOcsECPTAa1D% <br /> 0 oxer Home Address 22 West Yokute Aveunue nRrvm slsr�NaE% <br /> City Stockton STATE CA 71P 95207 <br /> McMrrg Address city NA Stam NA Zip NA <br /> CORPOINTON�+K INDIVIwaL❑ PARTNERSHIP❑ FWAGENOY❑ +m❑ <br /> FACILITY FILE <br /> FACHIn ID% Crtos4Ri[F ID# AccWWIDO INvll <br /> COMPLE7-E7HEFoLLol BUSINESSIFACILITY/SITEINFORMATR)N.' <br /> Is this a NEW Business LOCATION notpreVlously regulated by the EW41RONMENTALHEALTH DEPT.? yes ❑ No t[ <br /> Is this en EXISTING Business LOCATION but a NEW TYPE of regulated Business? Yet, ❑ No <br /> BMRNEs.UFAaunISHENAME Vacant land APN141-090-37, APN141-100-26, APN141-090-38, APN141-090-40, APN141-090-39, <br /> "AP 4- - - and APN171-090-36 ri0rre% Buumays Isnnuse <br /> SITEAiolseae 1943 East Fremont Street <br /> Cm Stockton <br /> STATE CA LP 95205 <br /> `SPAnuor Su,•vmooneprnioT WOAnon Coon NCH KM <br /> MaiIM9 Atldtem KD7FFE/ZFMlrwn fac/lityAddreae NA <br /> Attention:er CereOf fop%araalf <br /> MaIBng Address City N41_ - STATE ZP <br /> SIC C--. APN% ,. <br /> +Ill PARTY BILLING INFO' Camp/Ste/!Billing Party is different from Property Owner or Facility Operator identified above. <br /> `SUSNEse NAME Parisi? and Small ,-:A Professional law corp Attenuoe:wCere Of fopbusnafWilliam Pariah, seq. <br /> Mailing Address 1919 Grand Canal Boulevard PnorE 209 952-1992 <br /> ory Stockton srATE CA ZIP 95207 <br /> A-aawArAooBFCe for fees al Charges OWNER FADILtTYIBUSINESS THIRD PARTY BILLING <br /> B W o AND�,Q,NPL Ncs AcmNo XDOAtENT: 1,the undersigned Applicant,ell that t sm Ne Owver,Opemror,or.tmhorized Agent of this Busineea,and I ad:aow[edge that an JRiufo rFeet, <br /> �Pervranes,En£oAcexervTCxARces"Well Houur Cxracrs essarhtd with Nia eperntlon aaFll Le billed m me a[Ne addrms idendeedabare as Ne AttnrmTAmeess Wr thh ala.i abo c fy Nat <br /> '16B information Provided on this appileadon N true Rod correct;and that all regulated Seth itiet will be performed In accordance with all applirahle SAN JOAQUN CQU'RY Ordinance Codes and/or <br /> jSinndarda and STATsand/or F}9ERAt.Laws and Regulations.As Ne uodenigned owmey Pperotor,or agent afthe property basted at the above fadlity/si a address,l hereby authorize the release of <br /> dy and at sesues and esriroemevhl awastra t info Boo m SAN Jul COUNTY ENVIRONMENTAL HEALTH DEPAR NT�u It' va and a can¢time It h <br /> provided to me or my repeal tare /� <br /> �a'N //PLEASEPRAW SIGNATURE s <br /> C APPLICANT NAME / �//Q,y` �$('j <br /> TITLE DRIVER'S ER'S LICENSE <br /> ✓I/fLrbt �wroc omn + <br /> APPruvatl sy onm Attionrmrw omen P,nnnal CemPbbed By Mate <br /> MASTER FILE RECORD-GREEN <br /> 29-M W/12/07 <br />