Laserfiche WebLink
; `_ ,w SIataglurntxiu�' ia[iien Health Department _ <br /> � GREEN FURK <br /> °aiE Mp�ER FILE RECORD INFORMAnON `TIPP2" <br /> OWNER FILE <br /> COMMMTHEFOLLowNGPROPERTY OWNER INFORMATION: 0&Earno OWNER GuainintytMrF ,,wmfEHD ❑ <br /> P NAM L lie C�1a v�r� (au ybN— 73� <br /> Fast , <br /> han <br /> BUSn NAME Soc SEC/TMM# <br /> Owner Nome Address 7'0�� Q—S ✓ �{t l�' Decvm's LtO9ViE7f <br /> City } ..J StAr ZW <br /> charmer Mailing Address <br /> Mailing Acidness;City stake Zip <br /> Yver re nW.+rRcrsrR <br /> rno u n runmm�nno.w.eoa.0 n l#n Aesaw❑ rasnnn❑ <br /> Fnatm ID# CRoss REFID# Ac;ouNTID# <br /> MPLETE THE FOLLOw7 G NF T7 <br /> Is this a Nm Business;LomnoN not previously regulated by the Ei w eoeim f AL HEAIIH DEPARTMENR YES ❑ NoA <br /> Is this an Edinshe Business LocAnoH but a(yNN�m T ,X <br /> YPE of regulated Business? Ym ❑ No <br /> BusaawfFAmnY J� ME 1(�E / 11.1.11E.t SteXv ice, <br /> SmAoott, stem# B�ptttara: <br /> t� 2) f�L� <br /> CRY F--�Yf.� STAIE Y!P <br /> Mailing Address ifDR7ERENritom Fa AIYAddFes Attention:or Care Of(opdorral) <br /> Mailing Acidness;CLP STATF <br /> THIRD PARTY BILLING INFO: Complete if Billing Party is different from Property Owner or Facility Operator identified above. <br /> Bususess NAME Attention:oYCare Of (optional) <br /> Mailing Address; PHon= <br /> ctrf STATE Zap <br /> for fees and charges OWNER FACILITY/RUSINESS THIRD PARTY BILLING <br /> Hit Nr.A"russet iAN�A�NowTvDrm= 1,the undersigned Applicator,certify that 1 am the Owner,Operator,or Autflnriud Agent of this Business,and 1 acknowledge that all PEAafrr FEES, <br /> FENA nU,ENFOACEMEvrCHAEGES and/or lfovnYCasa S associated with this operation will be billed tome at the address identified above as the AfrnGNr Annif for this sin. I also cerdfy that all <br /> information provided on this application is true and comet;and that all regulated activities will be performed in accordance with all applicable SAN JoAQmry Courvry Ordinance Codes and/or <br /> Standards and STATE and/or F$DE12Ai.Laws and Regulations. As the undersigned owner,operator,or agent of the property located at the above fadlity/site address.I hereby amborbe the release of <br /> any and all malts and environmental assessment infyrmatian *—dOAQUYY-COLMITY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same date it is <br /> provided to me or my representative <br /> Pr cecr PRIIR <br /> APPLICANT NAME \ SIGNATURE, <br /> - �� --- w JeP j d)Ck nd e�' <br /> TLTLE DRIVER'S LICENSE# ' <br /> trNarocoRV REoufxEol <br /> s _ <br /> ffting Office:Processn9 Completed BY- Date=.i^,'f^.._ffffi t o'vrr. <br />