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r••— r';4s'r;,me.:: rasnY^"-ra+;x:-�rx�r...—.w-s ,--r•�-.--`.i'- . <br /> s+'tTaeTmis" ¢.�.�.-�Y��r.rr:,„:; <br /> �x�art�Joa mrl�Coun �r61 hi°ealt'. a ice"` �nvlrailmenta ealtfnDrvlslo <br /> FORM (EH0015(REVISFA0723N7) <br /> DATE L MASTER FILE RECORD INFORMATION <br /> HA <br /> G D D ,;owNEw.iD UNIT IV <br /> _._ <br /> OWNER FILE <br /> �COMPLETE7HEFOLLOW/NGBUSINESSOWNER /NFORMAT/ON. CHECK/F OwNERCuartei✓nrorvacEN•.rr/EHD <br /> .................._....---.._..—_._............._—._.._----.._......_._---T'--'--"—T__'---'-'--'------.._...__._._w.__".__ <br /> {;. <br /> PHONE <br /> BUSINESS i I <br /> �'-------- i✓ ------=---------�------- �Zpy� � 2✓iz <br /> OWNER NAME <br /> �-- - <br /> _..._._.Jae......_... <br /> . <br /> _.........._.................................._.......... <br /> ._f.Y.X.._.__....__...__.'____.M.....__—____—..._. <br /> BUSINESS NAME(d dlffereRt fro Owner Na e i Soc SEC 1 TAx ID# <br /> r: OWNER HOME ADDRESS r�y/����� /I.7�1r /Pyy(//� Sj I DRIVER'S LJCENSE# <br /> City �j(/[. ��////��I ...""" STATE A/I j zip �S <br /> OWNER MAILING ADDRESS (WDIFFERENrfrom Owner Address) i Attention: orCare of (optional) <br /> Mailing Address City ' State Zip <br /> ?G <br /> CORPORATION INDIVIDUAL❑ PARTNERSHIP❑ LOCAL AGENCY❑ COUNTY AGENCY CI STATE AGENCY❑ FED AGENCY C) OTHER❑ <br /> FACILITY FILE <br /> . t'aa .: Clio IS+10" <br /> am <br /> COMPLETETHEFOLLOWING BUSINESS I FACILITY I SITE INFORMATION. <br /> Is this a NEW Business LOCATIION not previously regulated by the ENVIRONMENTAL HEALTH OIVISION? YES ❑ ND <br /> Is this an FmSTING Business LOCATION but a NEW TYPE of regulated Business 7 YE5 O No <br /> BUSINESSIFACiLJTYISITE NAME .(7�y �) <br /> SITE ADDRESS ^� �• ,r ' � !^ , / i SURBUSINESS PHONE <br /> E# i <br /> CITY ` /PA ' SrArE.. ' zip <br /> Mailing Address ifDIFFERENrfrom Facility Address i Attention: or Care Of(optional) <br /> ( Mailing Address City ! STATE i LP <br /> �, ,h+w""'Y' 'y ?..t y�k'�nY try •,• ura".'• �fn ���YF� a4 .. <br /> SIC.'CoDEf„ � sAPN: : ~�'�-. '�c��'?.�`� 2CoMME7 "�r��'� .' �L.,tG.,R.�ca:.,..n=.,...r....- t�'••: <br /> ............................................................._.............._.......---..._.......—_...........—........._............_.............._. <br /> BUSINESS NAME i Attention:or Care Of (optional) <br /> Mailing Address I PHONE <br /> CITY ( STATE I ZIP <br /> AccouNrADOREss for fees and charges OWNER FACILITYIBUSINESS THIRD PARTY BILLING <br /> BILLMG AND COMPLIANCE ACXNOWLEDGMENT`. 1,the undersigned Appticaot,certify that 1 am the Owner,Operator,orAut/mri,edAgent of this Business,and I acknowledge that all <br /> Pnwrffzes,PE AL77ES,ENFORCEHEVTCHARGES and/or HOURLYCHARGES associated with this operation will be billed to me at the address identified above as the ACCOUNTADDREu <br /> 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 ail applicable SAN <br /> JOAQUIN COUNTY Ordinance Cods and/or Standards and STATE and/or ttDERAL 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 /> 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 /> .'.APIPLICANT NAME �� �f��Gr/ � SIGNATURE � rVV�C�� �-V•4 �"'�(9� n��. <br /> DRIVER'S LICENSE U' /add <br /> -TITLE -f�"iL ! ✓� <br /> (PHOmr.Oav acoulRrn', <br /> ccw f &?C PProcessfnga C <br /> (1ZGZ� . . .9b;'///' <br />