BILLING - Laserfiche WebLink

Home Browse Search

San Joaquin County Environmental Health Department GREEN FORM DATE S LIZ�'3 MASTER FILE/RECORD INFORMATION "MFR" SNencn AnFec Fro FMn i—nNi Y OWNER ID# I� l `( (/ CASE# UNIT IV l lO MER FILE COMPLETE THE FOLLOWING PROPERTY OWNER INFORMATION., CHECKIF OWNER CURRENTLYONFILEWITH EHD PROPERTY OWNER NAME PHONE First MI Last BUSINESS NAME S 1 \r I A /i (^ �' SOC SEC/TAx ID# Clams D aC to v l," C' Owner Home Address (4+Zp V�Ul l S 1 DRIVER'S LICENSE# City STATE ZIP t;-2�{ 2 Owner Mailing Address 4 � t Mailing Address City State Zip TVDF nF QWNFRG CORPORATION INDMDUAL❑ PARTNERSHIP❑ FED AGENCY❑ OTHER❑ FACILITY FILE FAQLITY ID# CROSS REF ID# ACCOUNT ID# 5�13Lf MPLETE THEFoLLowiNG BUSINESS I FACILITY I SITE INFORmA710N., su U IS this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ NO ❑ IS this an EXISTING Business LOCATION but a NEW TYPE Of regulated Business? YES ❑ No ❑ BUSINESS/FACILITY/SITE NAME SITE ADDRESS zq o,4 , ( "j r—, 4 . - SUITE# BUSINESS PHONE CITY �TW� l�Vt STATE ZIP 1 tj 1 BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEY1 KEY2 Mailing Address ifDIFFERENTfrom Facility Address Attention:or Care Of(optional) L-i,ZOk- Mailing Address City STATE (� ZIP �Ze SIC CODE APN# COMMENT: THIRD PARTY BILLING INFO: Complete if Billing Party is different from Property Owner or Facility Operator identified above. BUSINESS NAME , /I ' II Attention:or Care Of (optional) m p Ivy� (]• ��s6-- -} �n CSS"6� 1 in c p F^Cc c. c,a [Mailing Address "1 O z— PHONE 3[p� —`3 D ` CITY L o R STATE G� ZIP drrnrrurdnnnccc for fees and charges OWNER FACILITY/BUSINESS THIRD PARTY BILLING Bl1.I.ING AND COMPLIANCE ACKNOWLEDGMENT: 1,the undersigned Applicant,certify that I am the 0,rner,Operator,or.Iulhorized Agent of this Business,and I acknowledge that all PERMIT FEES, PE,1v4L77ES,ENFURCENEA7CHARGES and/or HOURLYCHAR[:F_S associated with this operation will be billed to me at the address identified above as the A((Ot'%7'.-I �'S for this site. I also certify that all information provided on this application is true and correct;and that all regulated activities sill be performed in accordance with all applicable SAN JOAQt1N COUNTY Ordinance Codes and/or 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,1 hereby authorize the release of 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 provided to me or my representative. / r APPLICANT NAME �C LU PLEASE PRINT SIGNATURE l TITLE PV 1 ��QN �., �— DRIVER'S LICENSE# g C)�-37 R'3 1 (PHOTOCOPY REQUIRED) APProYed BY f �— Date 7 j.'- Accounting Office Processing Completed BY Data 29-02-002 April 25.2003 CONFIDENTIA