Laserfiche WebLink
P. 2 <br /> 1 1-1 0-1 999 2:d3PM FRO!'' wit p(P/„/_( ci <br /> 1za 'ii„Sv'. —.w LrL �C1t1iT1_F <br /> • GREEN FORM <br /> DATE MASTER FILE RECORD INFORMATION "MFR" <br /> UNIT IV <br /> SHADED AREAE FOA E:HD USE ONLY <br /> OWNER FILE <br /> CNECK/F OWNER CURRENTLYON fILE W)r)+EHO a <br /> COMPLETETHEFOLLOWINGPROPERTY OWNER INFORMATION: <br /> PHONE r <br /> PROPERTY /� <br /> OWNER NAME <br /> FY.M MI Ierl <br /> $oc SEc/TAX ID# S- <br /> Fowner <br /> NAME Go rl ^`� �^/Nl <br /> I�'V (', ` DRIVER'S LICENSE# 100 ' 3 / Z <br /> ome Address �`� ' S S N I <br /> ���` <br /> ::�:tSTAT"<:'nr ZIP -/S ,3 7 <br /> I <br /> eiling Addreae <br /> rf State Zip <br /> Mailing Address City <br /> Fe0 ACENCY OTHER <br /> CORPORATIONn INDIVIDUAL 171 PARTNERSHIP <br /> i p . oda a a FACILITY FILE <br /> Iy tr^,rt�. t }}_,. �{ i k li 'I ) i' 'NiF 7P,"f ••r >- �; n..r•_. ..Y aN� ,�;...,.•v,...,r�. <br /> .-.:.fgl",ItIRiA�EN*.r.�Ii9r9 <br /> COMPLETETHEFOLLOW/NG BUSINESS 1 FACILITY I SITE INFORMATION: YES No <br /> IS this a NEW Business LOCATION not previOu91y regulated by the ENVIRONMENTAL HEALTH DIVISION Z Yes ID NO <br /> Is this an EXISTING Business LOCAtTioN but a NEW TYPE of regulated Business,? <br /> BusmESS/FACILITY/SITE NAME <br /> SUITE# BUSINESS PHONE <br /> SITE ADDRESS S I�►M t <br /> STATE zip <br /> CITY ":.1.;:•.�.. :.,j:..:.,.,i:: itl:.= <br /> - - `i.".•"' �.s��:ar :.i:j"r{mtr ,:;i',Nly�!•!11 :r� - ��. <br /> _�_�.., ._, ., q <br /> .. .. 'L.-',�_ n �.Y.1 µftp <br /> ., .. ....a. ♦1 �.. ,. ].,�t� .. 1':�,� <br /> ...t. .._..n�.a.... .pit....il'Y..]IHCt.n./,.. Y Fh\:.. I.�.r..F ..i.-.. .�.. w.f.......-..�,....�...•.. <br /> ..... : :'� ,. .._. .. , <br /> t, 69Ai b <br /> I Attention. o On <br /> VSO. ' :...:....... ...... <br /> " '_"' "•"'" .-``- - r Care Of Opti aQ <br /> Mailing Address/tD/FFERENT frain Facility Address <br /> STATE ZIP <br /> Mailing Address City <br /> COMMENT;.,. -•r'' }. <br /> THIRD PARTY BILLING INFO.- Complete if Billing Party is different from Property Owner orFacility Operator identified above. <br /> 1 I At On`o r r ca C�f��ptio/ta/J <br /> BUSINESS NAME 1 C S-f C_ \ L)W I I M aj y� � i I <br /> W i� - PHONE / I J——•V 7/,xI D <br /> Mailing Address � J �..(.� r q-4L� <br /> STATE;C q ZIP �,J /O V <br /> CIN S (� J (�/Q ���•I S�-� ( r <br /> r I v OWNER <br /> FACILITY/BUSINESS HIRD PARTY EILUNG <br /> AGCPUXTAQV-RW for fees and charges <br /> BILLING AND COMPLIANCE ACKNOWLF.DC:MCNT: 1,the undersigned Applicant,Certify that I am the Owner.Operdror,or Authar$ed Agent of this fledRusibo,and 1 oekno.o[1NT that all <br /> pr.Kwrr/rCI Y,PCry U.r/Y_v,BN/'DRC"ENT CHARGES and/or HOURLY CI ARGm assocl ated with this operation will be billed W me at the address idcntifiLd above av the ALY.!)uNTApp/LEAN <br /> U' <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 ilccuRlancc with all applicablect the <br /> JOAQUIN COUNTY Ordinance Codes and/or Standards and S r,%rx and/or FFT)u ,Laws and Regulations. As the undersigned owner,operator,or agent of the property <br /> above facility/Site address, I hereby euthorrzc the release of any and all results and environmental assessment information to SAN <br /> .InAQl;ly COUi`TY l NV1120NMEN'rAL <br /> HEALTH DIVISION as$oon as it is available and at the same time it is provided to me or my representative- ^ /� ��� <br /> • PLEASE PRINT `► // �'� <br /> �� Qr WJ SIGNATURE 1K��+r.a`rJ{ <br /> APPLICANT NAME IBJ`(-)IQ <br /> _ ^A ^ DRIVER'S LICENSE It <br /> TITLE Ap'3c';T- /'�rJ ACO <br /> � D M-7pF b\r e'd�Y�t.tl�IrYpM/a'�n[y`.m' 11 loo <br /> TuSnnaZMRr �rn•':•run►an.1ir"�11I�-iM.::,Yh-Sf !I.7�.�,•i_ <br />