Laserfiche WebLink
ATEo25 <br />.:......;. . <br />MASTER FILE RECORD INFORMATION k•: r:. �..:. <br />3w�nm ww Po[EHLI u[[o[ r FORM {EH 0015(REYtaEp Dgt11197} <br />OWNER FILE <br />COMPLETE THEFOLLOW/NG BUSINESS OWNER INFORMATION: <br />..... ....................... .... <br />BUSINESS�(.C..IJ <br />OWNER NAME ----* <br />UNIT IV <br />CH -5011F OWNER CLRRENrLrOAypZZyWrjyEHO <br />---- <br />................_..... Fl�l—.... <br />._......—.._................,—— — — —— — -------; PHONE <br />BUSINE33 NAME (K different from OWrW Name) <br />SOC SEC / TAx IO S <br />OWNER HOME ADDRESS <br />DRIVER'S UCENSE <br />(:hv <br />STATE <br />ZIP <br />OWNER MAILING ADDRESS (ifD/FFERENTfrorn ownerAddress) <br />E Attention: op -Care of (opya�j <br />Mailing Address City <br />0 <br />EN <br />:ENOy ❑ COUNTY <br />FACILITY FILE <br />COMPLETETHEFOLLOW/NG BUSINESS/ FACILITY}/ SITE INFORmATION.' <br />Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH OnnsioN ? <br />Is this an ExISTING Business L.Ot ATION but Nr-wTroa „f.,....d,. <br />SITE ADDRESS <br />CITY 0 <br />t G✓ <br />Mailing Address ifD/FFERENTham FacXiyAddrass <br />■Mailing Address City <br />WIRD PARTY BILLING INFORMATION: <br />BUSINESS NAME <br />En <br />State Zip <br />Attention: or Care Of (opbamo <br />is different from Business Owner Identified above. <br />for fees and charges OWNER FAC1LlTyfflus nlEss THRID PARTY BILLING <br />AND COMPLIANCE ACKNOWLEDcmEN T.- L the undersigned Applicant, certify that I am the Onmer, Operctor, orAsitherged Agent of this Business, and I acknowledge that all <br />F)5= PENALn= EN77RCEMENP CHARGES and/or HOURLY CAAAcm associated with this operation will be billed to me at the address identified above as the ACCDUNr <br />E for this site. I also certify that all information provided on this application is true and correct; and that all regulated activities will be performed in accordance with all <br />le SAN JOAQUIN COUNTY Ordinance Codes and/or Standards and STATE and/or FEDERAL Laws and Regulations. As the undersigned owner, operator, or agent of the property <br />at the above facility/site address, I hereby authorize the release of any and aR results and environmental assessment information to SAN JOAQUIN COUNTY <br />)NMENTAL HEALTH DIVISION as soon as it is available and at the same time it is provided to me or my representative <br />PLEASE PRINT <br />1CANT NAME SIGNAT11Rt= <br />DRWEii S UCENSE * <br />