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I~1 #. #IUlki E# #C £ k t: e `;::;E # 'lO�l€ l" <br /> DATE MASTER FILE RECORD INFORMATION FORM {EH 0015(REVISED 0617 /971 <br /> XAYEOA$ <br /> M FO■ H Y�E O.Ly <br /> 11EE D L <br /> UNIT IV <br /> —OWNER FILE <br /> COMPLETETHEFOLLOW/NG BUSINESS OWNER INFORMATION: CHECKIF OWNER CURRENrLY ON FILE MTH EHD <br /> ......................................................................................................................................................................................................................................................................................................... <br /> BUSINESS i - i i PHONE <br /> OWNER NAME ---------=---------- ---�------- <br /> � <br /> ...................................................................Fist........................................2I..............................................Last......................................' <br /> BUSINESS NAME(If different from Owner Name) SOC SEC/TAX ID# <br /> ' OWNER HOME ADDRESS '1 S DRIVER'S LICENSE# <br /> CftY �� Q - STATE <br /> OWNER MAILING ADDRESS (ifD/FFERENrfrvm Owner Address) Attention:or Care of (opdona/) 1 (" <br /> Mailing Address City rti Q s E State/'_A. i Zip 9537 <br /> CORPORATION❑ INDIVIDUAL❑ PARTNERSHIP❑ LOCAL AGENCY❑ COUNTY AGENCY❑ STATE AGENCY❑ FED AGENCY❑ OTHER❑ <br /> FACILITY FILE <br /> Ftcs�f .it . :::::::: :;::::_::::::::;:><;::::.::;;>:.;::>:.::<:>':>�i��au�3#€#........... � <br /> COMPLETE THE FOLLOW/NG BUSINESS / FACILITY/SITE INFO <br /> COMPLETE <br /> Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DIVISION? YES ❑ No ❑ <br /> Is this an ExISTING Business LOCATION but a NEW TYPE of regulated Business 7 YES ❑ No ❑ <br /> 6USiNES3/FACILITY/SITE NAME <br /> SITE ADDRESS 1 HCl U1�C V� _ i SUITE# BUSINESS PHONE <br /> SS <br /> CITY � STATE ZIP at`- ��7 <br /> IX <br /> ZInp <br /> Mailing Address ifD/FFERENTfrom Faaffly Add, E Attention:or Care Of(optfona/) <br /> lip <br /> Mailing Address City E STATE zip 2 J <br /> . ................:..."............... ..A#"# <br /> THIRD PARTY BILLING INFORMATION: Complete if Billing Party is different from Business Owner Identified above. <br /> .......................................................................................................................................................................................................................................................---................................................, <br /> BUSINESS NAME ,�..4--4 ' i Attention:or Care O tfOna �a,^(' <br /> Mailing Address PHONE <br /> CITY STATE/ rT ZIP <br /> ACCOUNT ADDRESS for fees and charges OWNER FActu Y/BUSINESS THIRD PARTY BILLING <br /> [ a j <br /> BILLI:yG.AND COMPLIANCE ACKNOWLEDGMENT: I,the undersigned Applicant,certify that I am the Owner,Operator,or Authorised Agent of thisusiness,and I acknowledge that all <br /> PERMIT FEES, PENAL7TES, ENFORCEMENTCHARGES and/or MOURLY CHARGES associated with this operation will be billed to me at the address identified above as the AcrotwT <br /> ADDRESS 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 /> applicable 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 /> located at the above facility/site address. I hereby authorize the release of any and all results and environmental assessment information to SAN JOAQUIN COUNTY <br /> EINVIRONMENTAL 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 /> APPLICANT NAME SIGNATURE <br /> DRIVER'S LICENSE# <br /> TITLE <br /> Apcprovet#:Eiy ETat '' f�kaotitsnting OftSae l?sacesststg Cot>spiet #Sats <br /> H �� <br />