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Y <br /> Sa31.�O2 I!#T41ESt£ty . ...... !It?3!Y!T 5ersa£ess ,..1= v;tcsttenfai Fi�alth I7 oRVLoHso s Re taco osn tv <br /> DATE MASTER FILE RECOFfD INFORMATION .. V . UNIT IV <br /> a c.v <br /> CASE 3 .•SN f�fi iv�h' vS/..f£ <br /> OWNER FILE <br /> CHECKIF OWNER CURRENTLYONRLE MTHEHO E] <br /> COMPLETE THE FO ......... BUSINESS OWNER........... <br /> , <br /> /Ve <br /> BUSINESS [ j ---------1 P <br /> Ro�L ---- . �siy� 901 s3oq i <br /> OWNER NAME `---------------- ---`------- Lass._.._....__—_...._..._.._.., <br /> ..._FNS.L.....__.. .__..._.__.....:ML..........._..._._...—.�__..._ : A <br /> -' SOC SEG/TA%ID# �/H /C <br /> �ie �>Eadex .Zv c, artAdfa�� <br /> BUSINESS NAME(If diAemot from Owner Name) <br /> A n ; DRIVERS LICENSE# <br /> OwdER HOMEADORE58 CDS L«i e I �e lT OO 111 <br /> STATECa.CIxC. LP L� 1X Y+� <br /> °" s f l aCAyfkl1� CIA,- e� <br /> f ( t <br /> AttanUon y�Care oOps na0 <br /> OWNER MAILING ADDRESS (i/DIfFERENTfrom OwnerAddressJ YIOn �Eil P <br /> State i LP <br /> Mailing Address CRY <br /> CORPORATION INDIVIDUAL❑ It,-0 LOCAL AGENCY 13 CouN AGENCY C1 STATE AGENCY FED AGENCY 11 OTHER❑ <br /> FACILITY FILE <br /> n I.F'ACTLiTY£D iR <br /> CRCSssREE£D# Accour<"'•• ; <br /> COMPLETE THE FOLLOWING BUSINESS/ FACILITY / SITE INFORMATION-' YES ❑ No AJ/ <br /> Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DIVISION? YES 0 NO III <br /> Is this an EXISTING Business LOCATION but a NEWTYPE of regulated Business? <br /> jr <br /> BUSINESS/FACIDTY/SITE NAME <br /> BUSINESS PHONE <br /> SITE ADDRESS �/� S fTGIYC�YA SfYee t - Cz°g� gy8' 881 <br /> ST <br /> '�i` ZJP qsa Oa <br /> CITY <br /> 4r <br /> Attention:or Care Of(opUona/1 <br /> Mailing Address/IOIFFERENTfrom FacdityAddress —,It MLx�re <br /> STATE LP <br /> Mailing Address City _... <br /> ,•?aar,`.`t <br /> :SIC'CoDE :'ba.''i:x APlilFetije „ <br /> THIRD PARTY BILLING INFORMATIOk' COmple a/f BIIIIn9 Party .. different ff0I776US...... OWf10r/t�e/!t/{/e a ave. . <br /> .or Care Of Norval <br /> / Attend (op ) <br /> BUSINESS NAME �(�f Cry. 70NPS _ <br /> �✓J V 1 YO � <br /> Mailing Address U ✓lm�� Ale /00 . P140NE(q/6) 53s- o aoo <br /> CRT �IY I.! STA • LP <br /> erA00REs for fees and charges OVYI•lER <br /> FAciftu I INESS THIRD PARTY BIWING b oaU <br /> BILLrNG AND CONPLIA.NCE a.CIC1OWI.EDGMEi'r: I,the under igned applicant,certify that I am the Owner,Operator.or.audsorC.ed AgeN o ea and I acknowledge that all <br /> PEjuezr FEES. PENALTIES. ENFORCEMENT CRARGES and/or HOVRLr CHARGES associated with this operation <br /> Nd that all billeulated activities wiI the ll to me aIPerformeedaino accordance� <br /> .ADDRESS for this situ I also certify that all information provided on this application u nue and correct; E <br /> applicable or this AQGIN COL7TTY Ordinance Codes and/or Standards and S7ATI:and/or FEDERAL Laws and Regulatiom. As the undersigned owner,operator,or agent of the propem <br /> located at the above facility/site addr,a I hereby authorize the release of.any and all results and environmental assessment information to SAN JOAQ[JLY COUNTY <br /> ENVDtO`T`[EYTaL HEALTH DIVISION as soon as it is available and at the same time it is provided to me or my representative. <br /> ��(/� <br /> PLEASE PRINT <br /> / w <br /> APPLICANT NPC7 a^• y��PC SIGNATURE <br /> AME _ <br /> TITLE IId DRIVER'S LICENSE III // <br /> PProve:d:6yAQCWnhng OHbO PiOopSin4 Y <br /> i >Date '7� <br />