FIELD DOCUMENTS - Laserfiche WebLink

Home Browse Search

;��SdFi1D'Y � . M l GRaN FORM ^'E MASTER FILE RECORD INFORMATION "MFR" 285.06 rL�L a OWNERID# CAsrk rte '40 UNIT IV ENVIRONMENT �{�L OWNER FILE COMPLETE T ERTY OWNER INFO/tMA770N; CNEcxrF OWNER GLRREmLronFrte wmfEHD ❑ PAOPERn OWNER . � 1 PHONE HANE Flat AM Wn BUSINESS NAME SOC SEC/Tout ID# S-r )DLcq cc •p�� t Owner Hotrte Address k-)0150 -)pi50 V l JV L DRrVEWS LICENSE# city -c n � STATE owner Hailing Address 1 7 qV I t9 A)tcpt_LD l.Tf Mailing Address City .^.r n_" ,. s+a�Gp, 'P Tvor nr nwxrncxm ��T fnoonoennx❑ Tunrvtdw ❑ DARTrernwm❑ FrTs aenarv❑ ��❑ C�bn 2\ # MOO VK') 5 l '1'12 IbMuwuw':;MOO E LL INFORM=& Ale 36 YES No Is this a Nm Business LocanoH not previously regulated by the ENvsnoeumemrA 14E rH DEPARTMENT? ❑ ne ❑ MOO YES Is this an E%IssING Busimass LanoN but a NM TYPE of regulated Business 9 u ❑ No ❑ BusntEss/FAotnx/Sin NAME VYn J S t_a r y'A Ce:> SInADOnE55 # BUSINESS PHONE CM STATE ZIP c � g X37 _ Douro Or SUPERv1soRDISr a I I LocanoNC,OtiEt ,I � , ,r ,•-,. �. IftY2,.,`?5'r� k •� •. Mailing Address ifOIFFERENT6onr FacilityAd11We It r Care of(optional) Mailing Address City STATE ISP • +. � I t ,3� COHHEHr:. �wsaaT.t.,x<x,4k=ax.Yliu^a.`,u_.as.::+x. w THIRD PARTY BILLING INFO: Completeif Billing Party indifferent from Property Owner or Facility Operator fden/ified above. BUsrN65 NANE Attention:or Care Of (optional) o,? fJ 5 L-zt �-{�,-� )�� d Ll l/ Mailing Address VI Pq N(C_t�'Z—c> PHONE 9007_936-- 6 v C:M STAn Zm Accaw T AaaRLSS for fees and charges nWNER FACILiTYIRUSINES.0 THIRD PARTY BILLING R r Texrr ArKNOM"GMeNT: I,the undersigned Applicant,certify that I am the Owner,Opermar,or Authorized Agent of this Business,and I acknowledge that all PERMIT FEES, P£NALHES,ENMRCEMEWCIIARGER and/or HOURLYCHARGU associated with this operation will be billed to me at the address identified above as the Arcolne'AnngeM for this site. I also certify that all Information provided on this application is true and correct; and that all regtdated activities will be performed in accordance with all applicable SAN JOAQNN Cct m Ordinance Codes and/or Standards and STALE and/or FEDERAL Laws and Reguladom. As the undersigned owner,operator,or agent of the property located at the above facility/site address,I hereby authorize the release of any and all muffs and environmental assessment information to SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It is available and at the now time His provided to me or my representative. PLEASE PRINT APPLICANT NAME SIGNATURE — 11ar.»�� TITLEDRIVER'S LICENSE# lJV I RnwT/tn N�Y�'✓✓ Vl�h.)f�C!-G�� (PHOTOCOPY MWIRED) r. v,... ved*'"By' •. a'te, i"rtrs34S, n"�"a'.l.t.. _ nhng Office Processirg CGmplebed,B,y.