Laserfiche WebLink
San Jo uin County Environmental Health -,partment <br /> A \--,Xi GREENFORM <br /> DATEZ < D MASTER FILE RECORD INFORMATION "WIFR" <br /> SHADED AREAS FOR EHD USE ONLY OWNER ID# O O C�/1 CASE# U M T IV <br /> OWNER FILE <br /> COMPLETETHEFOLLOW/NG PROPERTY OWNER/NFORxiiinoN: CHECK/F OWNER CURRENnyoNnixion7/EHD El <br /> PROPERTY OWNER NAME PHONE <br /> First MI Last <br /> BUSINESS NAME V 1 y SocSEc/TAxID# <br /> Owner Home Address i DmvER's LicENsE# <br /> city L O� 1 1 STATCA <br /> j/� ZIP q S <br /> Owner Mailing Address S Li <br /> 1 �/f <br /> Mailing Address City ock, State l ? Zip <br /> CORPORATION❑ INDIVIDUAL>( PARTNERSHIP❑ FED AGENCY❑ OTHER❑ <br /> FACILITY FILE <br /> FACILITY ID# ! ^ CROSS REF ID# ACCOUNT ID# O O �, INV# <br /> COMPLETETHEFOLLOW/NG BSUSI NESS/FAC ILITY/SITE/NFORNATiON: <br /> Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPT.? YES ❑ No <br /> Is this an EXISTING Business LOCATION but a NEW TYPE Of regulated Business? YES ❑ No <br /> BUSINESs/FAcILTTY/SITE NAME 1 <br /> SITE ADDRESS J • ✓ SUITE# BUSINESS PHONE <br /> CITY J r „) I STATE(,—'/"1 ZIP q S z <br /> BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEY1 KEY2 l• <br /> Mailing Address KD/F RENTfi»m Faa111yAddfvss Attention:or Care Of(opNww1) <br /> Mailing Address City STATE ZIP <br /> SIC CODE APN# COMMENT: <br /> THIRD PARTY BILLING INFO: Complete ifBilling Party is different from Property Owner or Facility Operator identified above. <br /> BUSINESS NAME Attention:orCare Of(opVonal) <br /> 1. Vl ✓1 <br /> Mailing Address 2 S 1 � PHONE <br /> Cm S� \ P Oe-\ STATE G�•LJ zip <br /> for fees and charges OWNER FACILITY/BUSINESS THIRD PARTY BILLING <br /> BILLING AND COMPLIANCE ACKNOWLEDGMENT: I,the undersigned Applicant,certify that I am the Owner,Operator,or Authorized Agent of this Business,and I acknowledge that all PERMIT FEES, <br /> PENALTIES,ENFORCEMENT CRARGES and/or HouRLYCIIARGES associated with this operation will be billed tome at the address identified above as the AccouNTADDRESS 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 JOAQUIN COUNTY Ordinance Codes and/or <br /> Standards and STATE and/or FEDERAL Laws and Regulations. As the undersigned owner,operator,or agent of the property located at the above facility/site address,I hereby authorize the release of <br /> any and all results and environmental assessment information to SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my representative. <br /> APPLICANT NAME PLEASE PRINT� SIGNATURE rv1�� 1iN1(��ti/lZJ✓ <br /> TITLE - DRIVER'SLICENSE# <br /> co (PHOTOCOPY REQUIRED% —�•' <br /> APP�BY Date Accounting Office Processing Completed By Data 3 D <br />