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� P <br /> t a �l'o'a° 1 G�oun, ' �r'�F,`�ealtk>�IS�ert,tce Enulronme"riCiealtF "Diviswn ';�r'� -'' <br /> DATE - a� 'UU MASTER FILE RECORD INFORMATION FORM (EHDotstREVISEDoyrzasT7 <br /> S-MIED-.1 Bron EHO V.EOaY OwN D -qg UNIT IV <br /> Ft Dj)0 ��(7 OWNER FILE <br /> ?? COMPLETE THEFOLLOW/NG BUSINESS OWNER /NFORMAT70N' CHEcK iF OWNER CURREvnYON FILE win/EHD <br /> -4................................................................._._........_....................._._.................__._....----- <br /> 9t , .._........____......_..._..._............_............................. <br /> _._—........_............................................. <br /> BUSINESS <br /> PHONE <br /> OWNER NAME -- 1YYde ----------- --\ *_'✓ <br /> --------------i l til j <br /> ............................ ..................rat................_.......... _ .....la......._........ . __...................tax................................._.._: llo ! / <br /> BUSINESS NAME(If different from Owner Name) Soo SEC I Tax ID# <br /> G ro e lrj <br /> OWNER HOME ADDRESS DRIVER'S LICENSE# <br /> city <br /> I 1 acy $TATEC a L° 9s3 �6 <br /> p ,1 <br /> .�' OWNER MAIUNGADDREaS (ifOIFERENTIrom Owner Address) ; Attention: or Care of (opiYonal) <br /> ri. <br /> Mailing Address City <br /> i State Zip <br /> n <br /> n <br /> CORPORATON❑ INDIVIDUAL❑ PARTNERSHIP❑ LOCAL AGENCY❑ COUNTY AGENCY❑ STATE AGENCY❑ FED AGENCY❑ OTHER❑ <br /> Mo 0 l�,D h FACILITY FILE <br /> ='FAti1�ITr1D "'.v.>..r' c Eaoss REFiDe ''�A'ccouNrlIX"7 � �„.. .,�x*�s+t�E ' <br /> IN <br /> COMPLETE THEFOLLOWINGpBUSINESS/ FACILITY/ SITE /NFORMAT/ON: <br /> Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DIVISION? YES ❑ NO ❑ <br /> Is this an E%ISTING Business LocAnoN but a NEw TYPE of regulated Business? YES ❑ NO ❑ <br /> BUSINESS/FACILITY/SITE NAME <br /> Kass ProT�,/ <br /> SITE ADDRESS y1 Te 1n� -1y. /J <br /> �l 15-711/1 VGhIIA f\0Q� SUITE# BUSINESS PHONE <br /> $oy <br /> CIN 11 C $TC/� i ZIP <br /> .w:a,.:.-.rsrn 1. t�,c- ° <br /> Mailing Address if0/FFERENT from Facility Address i Attention:or Care Of(apUona/J <br /> Mailing Address City <br /> STATE : ZIP <br /> THIRD.PARTY.BILL.ING INFORMATION: Cotnpi.etefiBllling Party is different from Business Owner ldentifiedabove. <br /> ................................. ......................_..................._..._........_............. <br /> -..................... <br /> ............._..............._._........... <br /> BUSINESS NAMEI� p i Attention:orCare Of (optlonal) <br /> NuahcP 1� nu r6l7Me✓1+Q <br /> Mailing Address <br /> /Kll JV W 1I 1� WQ�J PHONE <br /> /o[og '-162_le)66 <br /> CITY STATE] l� ZIP <br /> Accou✓rAoo rEss forfees and charges OWNER FACILITY/BUSINESS THIRD PARTY BILLING <br /> BMLING AND COMPLIANCE ACKNOWLEDGMENT: L the undersigned Applieant,certify that 1 am the Owner.Operator,or Aulhorl:ed Agent of this Business,and I acknowledge that all <br /> > PERM?FEES,PENALTIES.ENFoRcEwEvTCHARGFs and/or HOURLYC/ GFS associated with this operation will be billed tome at the address identified above as theACCODMADORESS <br /> far this site I also certify that all information provided on this applieation is true and correct and that all regulated activities will be performed in accordance with all appfeable SAN <br /> JOAQULN COUNTY Ordinance Codes and/or Standards and STATE and/or FEDERAL laws and Regulations As the undersigned owner,operator,or agent of the property loested at the <br /> $`above facility/site address, 1 hereby authorize the release of any and all insults and environmental assessment information to SAN JOAQUIN COUNTY ENVIRONMENTAL <br /> Si HEALTH DIVISION as soon as it is available and at the same time it is provided to me or my representative. _ <br /> PLEASE PRINT Iy 0(� <br /> ,[ APPLICANT NAME (+1�� M I ln�m� SIGNATURE <br /> TITLE 5 O _ DRIVER'S LICENSE# <br /> "'� I IPHOTo,opy RF0111RFnl <br /> - ApprOVBd6 � ew wha.,...`Y. 9LK"^ML#'•L^�V+"�* <br /> I fv-,....�.....•..-•Y,. �-'��. Da �,c+�vwv- 9 ng P Y:e>.. _DateV.. '.� '. ',, <br /> Aeeountln ORlce Proapstf Com Ieted B a� ,s,T <br />