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5att.Icla fli t Ct unt�PUMC Wealth Services Environ ectal Health Division <br /> FORM IEHWINF tsEu0GJ1I9T) <br /> DATE MASTER FILE RECORD INFORMATION <br /> a p1. rHa . ea,. flWNEA tDF � :: CASE#' UNIT IV <br /> OWNER FILE <br /> COMPLETETHEFOLLOW/NGBUSINESSOWNER INFORMA TION: CHECKIF OWNER CupeENrtYov FRE wiTHEHD � <br /> ................................................................................................................................................._.................__.........._...._............ .....,.........................._......_..._...._..._................................ <br /> i <br /> BUSINESS <br /> OWNER NAME <br /> (HONE <br /> ...................................................................Fl3.t........................................W...............................................TALL............_............ <br /> __ <br /> BUSINESS NAME(if diRerant from Owner Name) // SOC SEC/TAa 10# <br /> OWNER HOME ADDRESSC- DRIVER'S LICENSE# <br /> /� /asr Kanrrrlt <br /> Cit'/ ��QGGf T�a� STATE LP �Sao(y <br /> OWNER MAILING ADDRESS ()f0/FFERENTfronIOwner Address) I Attention:or Care of (ra7dona/) <br /> Mailing Address City ` State ': Zip <br /> CORPORATION❑ iNDIVIDUALkg PARTNERSHIP❑ LOCAL AGENCY❑ COUNTY AGENCY❑ STATE AGENCY❑ FED AGENCY❑ OTHER <br /> 07 <br /> FACILITY FILE <br /> FiYGp.TtY lff# <br /> E.0 <br /> I I : cl KC/iosiiEF lt3#�. :lA¢CD7UlkE113# <..:•. <br /> COMPLETE THE FOLLOWING BUSINESS I FACILITY I SITE INFORMATION: <br /> Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DIVISION? YES ❑ No <br /> Is this an ERISTING Business LOCATION but NEW TYPE of regulated Business? YES ❑ No ❑ <br /> BUSINESS/FACILITY/SITE NAME <br /> SITE ADDRESS i SUITE# BUSINESS PHONE <br /> 6A <br /> CITY \/ STATE `_ LP <br /> lin Sx racnwsDR IFS! n E'f nF i I ktvl - �I KrY7- <br /> Mailing Address if DIFFERENT from Fac//Ry Addm s Attention:or Care Of(op6ona/) <br /> Mailing Address City STATE LP <br /> THIRD PARTY BILLING INFORMATION' COMP10te if Billing Party is different from Business...Owner Identified above. <br /> ...................... . . ................ ..................................... <br /> BUSINESS NAME / Attention•.co-Care Of (opdena/) <br /> J/F IAT Wofs.! <br /> Mailing Address �f l F `� PHONE <br /> C" STATE/ LP I- <br /> C <br /> ACrOUNTAODRE for fees and charges OWNER FACILITY/BUStNE55 THIRD PARTY BILLING <br /> BII NI' IND COMPLIANfr ACHNOWLEDGNENT: 1,the undersigned Applicant.certify that I am the 0.".Operator,ordathorizeddgent of this Business,and I aclinowledge that all <br /> PERWT FEES, PENAL77ES. ENFORCEMENT CK GES and/or HOURLY CHARGES associated with this operation will be billed to me at the address identified above m the ACCOUNT <br /> aDORESS 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 JOAQUN 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 anv and all results and environmental assessment information to SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DIVISION as soon itis available and at the same time it is provided to me or my representative. <br /> PLEASE PRINT 2,,{ / <br /> APPLICANT NAME / �/'t'//(7( SIGNATURE <br /> / DRIVER'S LICENSE III <br /> , <br /> TITLE lou OI]IRPnl _ <br /> 'LAPP,-.-d BY Date �( Aecounb"cl office Processing Comptete f I <br />