Laserfiche WebLink
San Joaquin County Environmental Health Departm _ <br /> D ETI:FOAM <br /> OA'swl7w J) MASTER FILE RECORD INFORMATION "MFR" r� <br /> <xencneRcec FAR can um nx,v OWNER ID# OD19(I q I GSE# JUN UNIT01 IV <br /> ICC 7<OWNER FILE V�VrIRRn�O�N��NI ffl Htkj�y <br /> COMPLETE TNEFOLLOWING PROPERTY OWNER INFORMATION; :HD <br /> OWlvnxTlyryrjEx.Fn,I L EHD <br /> PROPERTY OWNER NAME NCAL <br /> 8 PHONE <br /> First MI Last i W <br /> BUSINESS NAME 11 'il_ Sot SECTAx ID# <br /> e l e�i�e �o n 4n• 11 <br /> Owner Home Address r1(� S1 f{e1 DRMR's UmAsE# <br /> City 6 u. )40 1 I STATE-r ZIP <br /> Owner Mailing Address <br /> Mailing Address Cfty State Zip <br /> T'smP rw nwxcvcxsv <br /> CORPORATION INDMDUAL❑ <br /> PARTNERSHIP El FED AGENCY❑ OTHER 11 <br /> FACILITY FILE <br /> FAa ry ID# QO151'/ -y CROSS REF ID# Acco NT IDMe&# INV# rl 1 "1 O <br /> 0MPLETE7NFF LL WING BUSINESS I FACILITY I SITE INFORMA710N- <br /> Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ No <br /> . Is this an EIasTING Business LOCATION but a NEW TYPE of regulated Business? \\ YES ❑ No ld' <br /> BUSINESS/FAaLm/Sm NAME <br /> SITE ADDRESS ✓✓ ^ II ( Sum# BUSENESS PHONE <br /> � S `� O S �. Pc��te�`A� Qca s �oQc1 <br /> CITY cmc 2Aq 83 s• 3�Z3 STATE Zip S 3 7 <br /> BOARD OF SUPERVISOR DIS'rTUR LOCATION CODE Kul KEr2 <br /> Mailing Address if DIFFERENr tram,Fadiityelddress Attention:or Care Of(optimal) <br /> Mailing Address City STATE zip <br /> SIC CODE APN# COMMENT: <br /> THIRD PARTY BILLING INFO: Completeif Billing Party is different from Property Owner or Facility Operator identified above. <br /> BUSINESS NAME Attention:orCam Of (optimal) <br /> Mailing Address PHONE <br /> Cr" STATE ZIP <br /> Amamm Anne cc for fees and charges OWNER FACILITYIBUSINESS THIRD PARTY BILLING <br /> g s NC non rON P INNCF ACKNOW rDGMENT: 1,the undersigned Applicant,certify that 1 am the Owner,Operator,or Antharired Agent of this Business,and 1 acknowledge that all P£RSHr FEES, <br /> PENALTIES,ENFORCEMENT CHARGES and/or HOURLY CHARGES associated with this operation wHI be billed tome at the address idend red above as the 4ccoll r4 DDR E(t for this site. 1 also certifv 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&xN Jo,tQUtN COUNT'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 enviro enm assessment' formaticn to SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it u available and at the same fime it is <br /> provided to me or my repr ata' p�;�7�,�r <br /> APPLICANT NA �//(((/,[J',y[�/ ICU(. 1—/t 4� SIGNATURE <br /> M e <br /> TITLEDRIVER'S LICENSE# <br /> D"-mbs i�ra2��faW� �t.�2 [PHOT«D�ED) <br /> Approved By Date I Accounting Office Processing Completed By Dale 4.0 <br />