Laserfiche WebLink
_ San Jo4.,,,In County Environmental Health DeNahtment <br /> DATE .• i \\ �� GREEN FORM <br /> I �L MASTER FILE RECORD INFORMATION MFR <br /> CHLnFn A..,,s Fna FHn,IGFos Y UNIT IV <br /> OWNER FILE <br /> COMPLE/FTHEFOLLOWING PROPERTY OWNER INFORMATION; CHECKIF OWNER CORRENTLyciv WITH EHD <br /> PROPERTY OWNER NAME 04�-/ IZy r1 S- PHONE LT <br /> 17� <br /> � First Ml / ✓ Last / <br /> BUSINESS NAME �•I v - /C�— (n � / �/ 1 $oC SEC/TAX ID# <br /> Owner Home Address 70� ' / �y DRIVER'S LICENSE# <br /> city Zm (T l <br /> Owner Mailing Address .J <br /> Mailing Address City State Zip <br /> TYPF r1F nwNrRswP <br /> CORPORATIo INDIVIDUAL❑ PARTNERSHIP❑ <br /> FED AGENCY❑ OTHER❑ <br /> FACILITY FILE <br /> [_:F:A:-LmID'# � 7CR07S-SREFID# F77TAC-CoUNT ID# _— INV# <br /> C—OMPI F7F THE FOL L 0 W <br /> INGNF MATION' <br /> Is this a NEW Business LOCATION not Previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ N <br /> Is this an Exis iNG Business LOCATION but a NEW TYPE of regulated Business? YEs No ❑ <br /> BUSINESS/FACILITY/SITE NAME <br /> SITE ADDRESS q 37i SUITE# BUSINESS PHONF5517'24 <br /> Cm t� r ! (�Q//� <br /> �Ly STATE ZIP 53 r `E, <br /> Mailing Address ifDIFFERE/VTfrom Fac//ityAddn:ss Atte tionAE Z+ : Care Of(optional) <br /> s ! V r "�/V <br /> Mailing Address City STATE ZIP <br /> THIRD PARTY BILLING INFO: Complete if Billing Party is ditferentfrom Property Owner or Facility Operator identified above. <br /> BUSINESS NAME <br /> DZ <br /> nr� , Attention:oiCare Of (optional)Mailing Address V ( ( (/yam J /_'L_fes' PHONE <br /> CIT'' STATE(/7., ZIP <br /> drC�nacc for fees and charges OWNER FACILITY/BUSIN <br /> THIRD PARTY BILLING <br /> Rn ImG AND COMPLIANCE ACKNOWLEDGMENT: I,the undersigned Applicant,certify that I am the Owner,Operato,or Authorized A � usiness,and I acknowledge that all PERAIITFEES, <br /> PENALNE.S,ENFORCEMENT CHARCFS and/or HOURLYCHARGES associated with this operation will be billed to me at the ove as the ACCGI/NTADDRES, 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 an at the same time it is <br /> provided to me or my rep /�� <br /> j��'W <br /> jf�' <br /> APPLICANT NAME PLEASE PRINT �L <br /> SIGNATURE <br /> TITLE DRIVER'S LICENSE# <br /> (PHOTOCOPY REQUIRED) <br /> APPrw�BY Date Accounting Office Processing Completed BY Date <br /> 29-02-002 April 25,2003 <br />