Laserfiche WebLink
• • <br /> San Joaquin County Environmental Health Department <br /> GREEN FORM <br /> DATE MASTER FILE RECORD INFORMATION "MFR" <br /> <�.orn..ar.erna PHD„«na,r UNIT IV <br /> OWNER FILE <br /> COMPLETETHEFOLLOH/ING PROPERTY OWNER INFORMATION;/ CHECKIr OWNER CURKENIIIDNFREWITH EHD <br /> El I <br /> PROPERTY OWNER NAME L ji PHONE <br /> First MI CC..//Ci Last <br /> BUSINESS NAME � // /C SOCSW/TA%ID# <br /> Quarter Home Address �/�� / l • yet dEF— DRIVER'SLi@SE# <br /> city gNi V STATE 2B 5�3 <br /> Owner Mailing Address <br /> Mailing Address City State Zip <br /> T'vor ns nwr.encurn <br /> CORPDRATRNI❑ INDIVIDUAL paRTNEn El FEDAGMCY❑ OTHER 11 <br /> FACILITY FILE . <br /> FAa¢TY ID'# - CRDssREFID# ACCOUNIID# INV# <br /> COMPI=THEFOLLOWZNG BUSINESS I FACILITY I SITE DyFoRmA770N.' <br /> Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ No <br /> IS this an E aSTING Business LOCATION but a NEW TYPE Of regulated Business? YES ❑ NO <br /> BUSINESS/FAmSrY/S/yyMN/�MIE ///I(//yam /f� <br /> SITEADORESS �/ W r-"✓ T VS`_ � I' Z SUIrE# BDSINEss PHONE <br /> CITY ,r/Jnr �, if STATE/T/Ii 2ID <br /> Mailing Address ifDIFFERENT/kion,Fad/ityAddr Attention: Care of(000kuaQ <br /> Mailing Address city STATE ZIP <br /> THIRD PARTY BILLING INFO: Complete if Billing Party is different from Property Owner or Facility Operator identif'ed above. <br /> BUSINESS NAME - Attention:or Care Of ( 'oris/) <br /> ALI <br /> Mailing Address e--77 <br /> CITY STA,EE/ ^IYi�J n_543ef—y �`/ J—/;v�_f[/iy1yr <br /> AccaulwAnnei"<for fees and charges OWNER FACILITYfBUSINESS THIRD PARTY BILLING <br /> I,the undersigned Applicant,cer0y that I am the Owner,Operator,or Aunhorired Agent of this Business,and I acknowledge that all PE.CSRTFEES, <br /> PENAJf&,ENPORCaSiNCcwGeSand/or HOURLY CtuRG£Savaciated with thisoperaden will be billed tome at the address idendfied above as the ArcQfWTJQoSvVT for this site l also certify that <br /> all information provided an this application is true and correct;and that all regulated activities will be performed in accordance with all applicable S.sNJOAQLTN COONty 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 authorise She release of <br /> 'any and all results and environmental assessment information to SAN JOAQUIN COUNTY F.NVIRONSIENTAL HEALTH DFPARTA4w as soo.JoKiflrj7sible and at the Same time it is <br /> provided to me or my rep P'... <br /> PlFt5E PRvr <br /> APPLICANTNAME SIGNATURE/, <br /> rinE DRIVER'S LICENSE <br /> Sir <br /> AppowABY TarRD) <br /> Date - Accounting Office Processing Completed BY Date <br /> 29-02-002 April 25,2003 <br />