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...' Sart Jaa`"tom County.._ X Health Servi <br /> ces Env rc7n ie FIE lCh Akv;sian <br /> DATE MASTER FILE RECOFFD INFORMATION FORM !EHOOtS(REVISE00611119T) <br /> a.aam..vs w.eND a.rn... .uERiD .:CASE$ UNIT IV <br /> OWNER FILE <br /> COMPLETE THEFOLLOWING BUSINESS OWNER INFORMATION: CHECKIF OWNER CURRENTL r ON FILE WTH END ❑ <br /> ....................._..........................................................._...................,.............._.........._.............-........_...._......_.._............._........__,._..............................._..............................._................... <br /> . <br /> BUSINESS i PHONE <br /> OWNERNAME r_________________ ________________________: <br /> ..................................................................r7/d!........_......_.._.................M!..._............_..............._....__...Lw........................._. <br /> BUSINESS NAME(If different from OWDer Name) SOC SEC/TAX IO# <br /> OWNER HOME ADDRESS DRIVER'SUCENSE# <br /> CttY i STATE i LP <br /> OWNERMAIUNGADORESS (if DIFFERENT from Owner Address) Attention:or Care of (optional) <br /> Mailing Address City State Zip <br /> j CORPORATION INDIVIDUAL PARTNERSHIP LOCAL AGENCY CouN AGENCY Cl STATE AGENCY FED AGENCY OTHER <br /> FACILITY FILE <br /> FAti.TrYkt7iC, .. ' t;RdSSREFTI##. : •r%cetDiuNTID#" <br /> COMPLETE THEFOLLOW/NG BUSINESS / FACILITY / SITE INFORMATION: <br /> Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DIWSION T YES ❑ NO ❑ <br /> Is this an EXISTING Business LOCATION buts NEw TYPE of regulated Business? YES ❑ No ❑ <br /> BUSINESSIFACIOTYtSITE NAME <br /> SITE ADDRESS i SUITE# BUSINESS PHONE <br /> CITY STATE ZIP <br /> k...ra.tOx EODE _ iSEv? <br /> Mailing Address ifD/FFERENTfrom FacitityAddrsss f Attention:or Care Of(opbonat) <br /> Mailing Address City STATE ! ZJP <br /> ,51F`.�ErD1>£ ,M1FKtF ( COMMENC_ <br /> THIRD PARTY BILLING INFORMATION: COMPlete if Billing Party is different from Business Owner Identified above. <br /> ...................._............................._.................................._.........................._............._......................................................,........................................................................................................._... <br /> BUSINESS NAME i Attention:or-Care Of (Optional) <br /> Mailing Address ; PHONE <br /> CITY ! NATE ZIP <br /> AccOUNTAODRfss for fees and charges OWNER FACRITY/BUSINESS THIRD PARTY BILLING <br /> BILLING kND COMPLIANCE ACt CRVLEDGMENT: I,the undersigned Applicant.certify that I am the Owner,OPerator,or Authori ed Agent of this Business,and I aclmowledge that ad <br /> PE21RT FEES. PENdLTTES, ENFORCEMENT CHARGES and/or HOURLY CHARGES associated with this operation will be billed to me at the address identified above as the ACCOUNT <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 S.ANJOAQUN COL?T'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 racilimtsite address, I hereby authorize the release of.any and all results and environmental assessment information to SAPI JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DVITSION m soon as it is available and at the same time it is provided to me or my representative I <br /> PLEASE PRINT <br /> APPLICANT NAME SIGNATURE <br /> TITLE DRIVER'S LICENSE# <br /> /pvninrn RV RFnI IRFnI <br /> Approved By Oa#e AccoDntirg Ofiiee Pioopsing Cormpteted by Qate <br />