Laserfiche WebLink
San Joaquin County Environmental Health Department <br /> DATE MASTER FILE RECORD INFORMATION "MFRS, GREEN FORM <br /> SHADE-AREAS FOR tHLU§EONLY OWNER ID# CASE 111 UNIT IV <br /> OWNER FILE <br /> COMPLETE TNEFOLLOW/NQ PROPERTY OWNER/NFORMAT/ON.' CNECKIF OWNER CURREAnzYm newnx END <br /> PROPERTY OAt ER NAME 'i iArA PHONEgvj-q3-jj� 52D <br /> First M1 Last V/ <br /> BUSINESS NAME SOC SECITAK ID# <br /> Owner Home Address DRIVER's LICENSE# <br /> City STATE LP <br /> Owner Mailitp Address ICI EaS� el <br /> Mailing Address City J 5 l �( state LP G <br /> CORPORATION❑ INDIVIDUAL❑ PARTNERSHIP El FIND AOENCY❑ I OTHER❑ <br /> FACILITY FILE <br /> FACI LT'ID# CROSS REF ID# ACCOUNT IO# INV# <br /> COMPLETE THEFOLii owma BUSINESS/FACILITY/SITE/NFORMAT/oM <br /> Is this a NEW B_Uslness LOCATION not previously regulated by the ENVIRONMENTAL HEALTH YES ❑ No00 <br /> Is this an EXISTING Business LOCATION but a NEW TYPE of regulatedBusiness?Business? YEs El No <br /> A No ' <br /> !, BUSINESSIFACILITYISITENAME 1^i� �+ L &5+ <br /> SITE ADDRESS 0 COu)k (Vil � VIII UUUU vv J SURE# BUSINESS PHONE <br /> CITY 5It? STATE C4 <br /> L/T OJ <br /> ZIP Czo <br /> BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEYS KEY2 I <br /> Mailing Address RD/FFERENrIrom FaciiityAddress Attention:or Care Of(opL"orla/J <br /> Mailing Address City STATE ZIP <br /> SIC CODE APN# COMMENT: <br /> THIRD PARTY BILLING INFO: Complete if Billing Party is different from Property Owner or Facility Operator identified above. <br /> BUSINESS NAME AttenUOn:orCare Of (optional)N4WIr5 �4w11 �iY �" fYnw/r <br /> Mailing Address(( ��Pr o t f[O pNpfg 3, �j rIr <br /> Cm WOJ 6f k Y STATE /Id LPyI (5c15� <br /> A x a �R for fees and charges OWNER FACILITY/BUSINESS ✓f THIRD PARTY BILLING <br /> BILLING AND COMPLIANCE ACKNOWLEDGMENT: 1,the undersigned Applicant,certify,that I am the Ono er,Oper ,er,or Anl/IWlfed Agent of this Business,and I aclmewledge that all PIuva T F££$ <br /> PENALTIFB,L'N'FORC£MrMCR GES and/or HOUKLYCNen,Esassocutcd with this operation will be billed tome at the address identified above as theACCOUNI ADUK£SS for this site. I also certify that all <br /> information provided on this application is true and correct;and that all regulated activities Bill be performed in areardance with all applicable SAN JOAQUIN COUNTY Ordinance Codes and/or <br /> Standards and STATE and/or FEDERAL Laws and Re,chunes, 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 EWIRONRIFNTAL HE:1LTIi DEPART as soon it is available and at the some time it is <br /> provided to me or my represenJfi( . <br /> PLEASE PRINT <br /> SIGAPPLICANT NAME gk ys„ NATURE <br /> TITLE `tWL5lenv _ DRIVER'S LIC <br /> ENSE# <br /> (PHOTOCOPY REQUIRED) <br /> Appromd By Date Amounting 01 oe Praomming Completed Sy Dere <br /> 29-002 Apnl 25,2003 <br />