Laserfiche WebLink
t` � ,,,�, I•� �Ete�I�E�_ .... E" 14 <br /> ETeat�h' <br /> ' Sa}'f moi© tI;tIF�;GO�UIIIt. FORM (EH00154REVISED06111/97) <br /> DATE MASTER FILE RECORD INFORMATION UNIT 1V <br /> f#WFFER fi3i�' CASES <br /> SMAOEO w11EM F0 EHD USE O�Ir � -'� <br /> OWNER FILE <br /> CHECK IF OWNER CURRENTLYONFILE WITH Elio U� <br /> COMPLETE THE FOLLOW/NG BUSINESS OWNER INFORMATION: <br /> .......................................................... <br /> . .................................................- PHONE <br /> BUSINESS ' <br /> OWNER NAME `— <br /> --------------- -- Last ` <br /> First ...................................................................... <br /> ........................................................................................................................................ <br /> SOC SEC TAx ID# <br /> BUSINESS NAME(If different from Owner Name) <br /> DRIVER'S LICENSE# <br /> OWNER HOME ADDRESS <br /> STATE ZIP <br /> chtY <br /> Attention:or-Care of (optional) <br /> OWNER MAILING ADDRESS (if DIFFERENT from Owner Address) <br /> State Zip <br /> Mailing Address City <br /> L1 STATE AGENCY C1 FED AGENCY L1CORPORATION❑ INDIVIDUAL❑ PARTNERSHIP C1 LOCAL AGENCY C1 COUNTY AGENCY OTHER❑ <br /> FACILITY FILE <br /> FacscTrr:fD# Jlioit►Fi[I#: ; e <br /> COMPLETE THE FOLLOW/NG BUSINESS I FACILITY /SITE INFORMATION: <br /> YES C1 No C3Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DIVISION? <br /> YES No <br /> Is this an EXISTING Business LOCATION but a NEW TYPE of regulated Business? <br /> ❑ ❑ <br /> BUSINESS/FACILITY/SITE NAME <br /> SUITE# BUSINESS PHONE <br /> SITE ADDRESS <br /> STATE ZIP <br /> Cm <br /> Attention:or Care Of(optional) <br /> Mailing Address if DIFFERENT from Facility Address <br /> STATE ZIP <br /> Mailing Address City <br /> SIC COEZE APN# Co3tt�HNF <br /> THIRD PARTY BILLING INFORMATION: omplete If Billing Party /s different from Business Owner Identified <br /> Cabove <br /> Attention:or Care Of (optional) <br /> BUSINESS NAME <br /> PHONE <br /> Mailing Address <br /> STATE ZIP <br /> CITY <br /> ACNTADDBESS for fees and charges OWNER FACILITY/BUSINESS THIRD PARTYBILLING <br /> COt/ <br /> BILLt.,,G:LVD CONIPLt.1.VCE ACIClioWLEDGNIF,NT: L the undersigned Applicant,certify that I am the Owner,Operator,or Authori;edAgent of this Business,and I acknowledge that all <br /> PER.1fIT FEES, PE%IALT7ES, E',-FORCE.11EN7 CHARGES and/or HOURLY CHARGES associated with this operation will be billed to me at the address identified above as the ACCOUVT <br /> or this site. I also certify tnlbr <br /> that all imation provided on this application is true and correct; and that all regulated activities will be performed in accordance with all <br /> ADDRESS f <br /> applicable ruthiQUCt COUNTY Ordinance Codes and/or Standards and STATE and/or FEDERAL Laws and Regulations. As the undersigned owner,operator,or agent of the property <br /> located at the above facility/site address, I hereby authorize the release of any and all results and environmental assessment information to SANJOAQUIIY COUNTY <br /> ENVIRONNMENTAL HEALTH DIVISION as soon as it is available and at the same time it is provided to me or my representative. <br /> PLEASE PRINT <br /> APPLICANT NAME SIGNATURE <br /> DRIVER'S LICENSE# <br /> TITLE (PHOTnrnPY RFOtIIRFn1 <br /> c Approved By : Date /ltccot3rtting Office Froet�sing'Cotn{Iteted$y:.. i Date <br />