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o m .=�^An4imapffi1• :ealt; e ce nulronmenta sahF Divlslo <br /> FORM (EH0015(REY19EU07a319T) <br /> DATE s MASTER FILE RECORD INFORMATION <br /> SHAIIED R END VSE OXLY UNIT IV <br /> OWNER FILE <br /> COMPLETETHEFOLLOWING BUSINESS OWNER INFORMATION: CNfCK fF OWNER CueaF.vrLroN FnewlrNEHO <br /> .— <br /> ....................................................................................._...._._T................................................ __...... <br /> ' BUSINESS i j <br /> �___A47e��____- ___—___��� ________, PHO/NE <br /> OWNER NAME <br /> ..........................._.F.rA................._...........__._..IN......_.........._.__......................Um............ <br /> ..........................: <br /> BUSINESS NAME(d different#7p) Name i SOC SEC I T"ID# <br /> OWNER HOME ADDRESS //.T�l� /><fLI//� �T i DRIVER'S LICENSE# �,-yJ <br /> City � STATE/JAI i Z!P 4S G 72— <br /> r� OWNERMAILINGADDRESS (%fDIFFERENTfrom OwnerAddressJ ; Attention:orCare of"(ro"pUona/J <br /> State i Zip <br /> Mailing Address City 7 <br /> i. <br /> CORPORATION INDIVIDUAL PARTNERSHIP 13 LOCAL AGENCY COUNTY AGENCY STATE AGENCY FED AGENCY OTHER❑ <br /> r,lj ' ' FACILITY FILE �s <br /> 7D e P Accouifrsp", - .: :�w N of <br /> a_. COMPLETETHEFOLLOW/NG BUSINESS/ FACILITY/ SITE INFORMATION. <br /> Is this a NEW Business LOCATION not previously regulated try the ENVIRONMENTAL HEALTH DIVISION? YES ❑ NO <br /> ?i. <br /> Is this an EXISTING Business LOCATION but a NEW TYPE of regulated Business 7 Y C] ND fQ� <br /> Y. BUSINESS/FACILITY/SITE NAME <br /> SITE ADDRESS SUITE# BUSINESS PHONE <br /> d cS7�llCj / sT� € L�j"lOZ <br /> CITY <br /> r ,�.,_:. ..;,;":^ ':r-'•.:r �.. x. Pc'- 4{T+.`4�"" ...`A5".:.,:s..: [" � ��,._ .�:1", h"!K r' ° <br /> Mailing Address ifDIFFERENTfrom Facility Address ' Attention: or Care Of(optional) <br /> a <br /> Mailing Address City STATE ' ZIP <br /> .,Yr ...m�� � <br /> ' SIC',GOD <br /> � APN <br /> THIRD PARTY BILLING INFORMATION: Complete if Billing Party isdlfferentfromBusiness Owner Identified above. <br /> .. ..................................................................................................._......................_....................._................................................._._..............__._.................................................................. <br /> ; <br /> BUSINESS NAME Attention:or Care Of (optional) <br /> Mailing Address ' PHONE <br /> OITv STATE ZIP <br /> i' <br /> AccouNTADOREs� for fees and charges OWNER FACILITY/BUSINESS THIRD PARTY BILLING <br /> BILLING AND COMPLIANCE ACKNOWLEDGMENT. 1,the undersigned Applima4 certify that 1 am the Owner,Operctor,or Authorized Agent of this Basilicas,and I acknowledge that all <br /> {:PE",T FEES,PFivALTIE3,ENFORcmilENT Cx GFs and/or ROURLYCHARGFS associated with this operation will be billed tome at the address identified above as the ACCOUNTAODRFSS <br /> for this site. I also certify that all information provided on this application's true and correct and that all regulated activities will be performed in accordance with all applicable SAN <br /> $' 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 located at the <br /> above facility/site address, 1 hereby authorize the release of any and all results and environmental assessment information to SAN JOAQUIN COUNTY ENVIRONMENTAL <br /> C HEALTH DIVISION As soon as it is available and at the same time it is provided to me or my mpresentative. <br /> PLEASEPRINT <br /> APPLICANT NAME � �( yT �GJ SIGNATURE <br /> .TITLE DRIVER'S LICENSE# <br /> IOU RFn) <br /> a, <br /> g <br /> Apo sAeeouxnatlnvg+'Office PrOceeascsYncCotimP <br /> at ?" 'S ,darespa ,, •s.ru <br />