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DATE MASTER FILE RECORD INFORMATION FORM I0+0015(REvrse006nt97) <br />...:..F..:.:.`. :;UNIT ;.�.•j.M..-;:;.. $�.:'•<t .. r. + r.''.n '. - L �< vX.>.".hti vFrS%jS.::SfTI% i:>}. :l.+L°{r':.jypC'v.'•%.•?t. <br />I <br />100-4.0 <br />Sm••ARES a PiloED aa[OMLv : <br />.:v........ :avf-:.v:. .r+:.v:n6.n..: ,+r.•. nvC -n- <br />OWNER FILE <br />COMPLETETHEFOLLOW/NG BUSINESS OWNER /NFORMAT/ON. CHEcxir OWNER CUMWArTLronr-7cEwrrHEHO <br />............................. ._......... _ <br />PHONE <br />BU31NE33 <br />OWNERNAME ` -----------------'.`_----y'---------- -----� <br />......................... <br />BUSINESS NAME (if different #vf" Owner Name) SOC SEC1 TAX 10 <br />OWNER HOME ADDRESS DRIVER'S LICENSE i <br />Ctt <br />Y STATE 7JP <br />OWNER MAILING ADDRESS (NO/FFERENrf -om OwrrerAddr*") Attention: orGars of (oP aal1 <br />Mailing Address City Slate 23P <br />CORPORATION C1 INDIVIDUAL 13PARTNERSHIP ❑ LOCAL AGENCY ❑ COUNTY AGENCY ❑ STATE AGENCY ❑ FED AGENCY ❑ OTHER C3 <br />FACILITY FILE <br />... a,......._..: f>f:. YM: <br />.. ..;_'vr..tr ...... <br />...... +... ,,•�+.:{v�;:a.,>.::�: �.._: -: ;: - i '{j. S:`..n -:: i•.......� � ¢'ter. \"k::S� p�>'.•jS.' ::.}.c J..�.�iji`::::: <br />...> >•.>:�-�:.:::>; .. .... - :.�>, 1�.�y'j'y�"��".• �y�yqj� r�I4"CQif1�i�' rrs?i•>.... :..�� <br />CnniPLETETHEFOLLowNG BUSINESS / FACILITY/SITE INFORMATION: <br />Is this a NEW Business LOCATION not previutasly regulated by the ENVIRONMENTAL HEALTH OMSION ? YES ❑ No ❑ <br />Is this an EXISMNGI Business LOCATION but a NEW TYPE of regulated Business 7 YES Cl No ❑ <br />NAME <br />SITE ADDRESS <br />/ <br />StfITE SBt1SIHESS PHONE <br />CITY <br />C '9D f' <br />^STA ZIP � „ <br />( �/i2,(� <br />•::....................::: :::.:.�::..:............ <br />...............:+.+........+....... <br />...............:... ......... <br />r.. .. :.+:..::::.->:: +.. ....c....>...,;.qyf {. <br />.�:.:::.: <br />,... . ,. ^-..: <br />.......:: .:: : <br />:.,..r.. ..:{>n:. R• <br />.... r....7w• ..... <br />:::::: r ....: +.. .. .:::...:::::....::.:... .i ......r v: y:.; :?<vj:4 ` .iii:: ' T`..' Lr{jf i{•::Y.v' i+::iiY{fn';i jYii: <br />c; .. k. Y .-.. .,,R {. { moi., r <br />.. R'.. �.-*x.. .. ��•.-:: n.:• ^�,� .,:> ::r::,.v:: Jj...:. Z'.?Rk° ,., o�.jir`:? , :{.:�:.;<•.,.,:.^<;qj$�: <br />Mailing Address if0/FFERENT&vm F-WtyAddr>ssts <br />' Attention. or Care Of (opdbraad) <br />Zip <br />Mailing Address City STATE <br />THIRD PARTY BILUNG INRORNATION: Complete if Billing Party /e different from Business Owner Identified above. <br />BUSINESS NAW ' r ' f . .J ;, ,� AtiMtion: arCare Of (opdiorral) <br />Mailing Address(_ - (.;�. "'r Q-irr�a `` PNGNE <br />Cm STATE ZIP <br />stccouNTAnnRF!r4 for fees and charges OWNER FACaJTYBUSINESs THIRD PARTY BILLING <br />BILLING AND COMPL(A14AX ACID'tOat.LDG,N12'r1• I, the undersigned Applicant, certify that I am the Owrw, Opernta►, or Aaraiorired Agent of this Business, said I admowledge that all <br />pERVIT IrE= p&uLT= ENmRCniMVr CHARGE!r and/or HOURLT CNARGEs associated with this operation will be billed to me at the address identified above as the ACCO <br />ApORESS for this site. I also certify that all information provided an this application is true and correct; and that all regulated activities will be performed in accordance with all <br />applicable SAN JOAQUU4 COt11YTY Ordinance Codes and/or Standards and STATE and/or F[DERAL Laws and Regulations. As the undersigned owner; operator, or agent of the property <br />located at the above facility/site address. I hereby authorize the release of any and all results and envirbnmental assessment information to SAN JOAQUIN COUNTY <br />ENVIItONMEYTAL HEALTH DIVISION as soon as it b available and at the same time it is provided to me or my representative. <br />PLEASE PRINT <br />APPLICANT NAME <br />TITLE <br />SIGNATURE <br />DRIVER'S LICENSE <br />(PHDTn -nov ocni rtocnl <br />