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San J ujn Cain PuaFfa FEeattFr Serzrlees°. Eiiv�oti rrta eatt#� Disr <br /> DATE .. ... <br /> MASTER FILE RECORD INFORMATION FORM (EHMISiREVISE00eH/9 TF <br /> '£ OWNE&FD# .�• CA9EFf" <br /> UNIT IV <br /> COMPLETE THEFOLLOW/NG BUSINESS OWNER /NFORMAV T/'ONR FILE CHECK/F OWNER CURRENTLYON F/(,E{yTH EHD <br /> ...................................................... <br /> ...........................:..................:.................. <br /> BUSINESS � .............................. ......._ _ <br /> OWNER NAME f..� HO��,r.. Yl -/. <br /> — -- .. AAAA..--'.�TU.... . ..f,-„-... .. <br /> NE <br /> ............................................................ <br /> .......First..... ................MI ... <br /> .................. ..........AAAA.:.?i.S.................... _ __ ' <br /> BUSINESS NAME If different from Owner Name) .. <br /> SOC SEC/TAX ID III <br /> OWNER HOME ADDRESS <br /> DRIVER'S LICENSE# <br /> city <br /> STATE 7JP <br /> OWNER MAIDNGAOORESS (fO/FFERENTfro Owner Address) C•"7 �7o�O�j <br /> Attention:or Cara of (opbcna/J <br /> Mailing Address City <br /> State ` Zip <br /> CORPORATION❑ INOIVIOUA H PART.-.•... pn <br /> LOCAL AGENCY COUNTY AGENCY STATE AGENCY❑ <br /> FED AGENCY❑ OTHER <br /> >: FACILITY FILE <br /> �BA'CtLtTYIQ}k• -`. CRass REFfQ#' - .. <br /> COMPLETE THE FOLLOW/NG BUSINESS / FACIA COUNT <br /> LITY/ SITE INFORMATION: t <br /> Is MIS a NEW Business LOCATION not PreviOusly regulated by the ENVIRONMENTAL HEALTH DIVISION 7 <br /> Is this an EXISTING BUSinesegulated Btminess 7s LOCATION but a NEW TYPE of r YES 13NO 0 <br /> BUSINESS/FACILITY/SITE ❑ No ❑TY/$ITE NAME � <br /> ;A,19 <br /> SITE ADDRESS <br /> A ��f.. ! SURE# <br /> BUSINESS PHONE <br /> [ �/l/�� i�/! <br /> CITY <br /> OcK 104, STATE <br /> �f o�O <br /> Mailing Address ifOIFFERENTh-o F /ty Add ss <br /> Attention:or Care Of(opbdna/) <br /> Mailing Address City <br /> STATE <br /> zip <br /> SIC CDDE �APN# <br /> HIRQ PARTY BILLING INFORMATION Complete/f BIIIIn PartrtY,./s different from Business Owner/dentified above. <br /> BUSINESS NAME <br /> / I ...........__.........._......._..—AAAA.. <br /> �F ii/A - �✓l�,L,_ Attention:or Care Of (opGnrsa/) <br /> Wailing Address <br /> /' /,`�y S� i PHONE <br /> :ITY <br /> �01� %< S � sr7 <br /> O(fY riT✓1.1 sTATE/A/j LP <br /> CQf/NTAOORW for fees and charges OWNER FACILITY/BUSINESS L.µ]” i <br /> THIRD PARTY BILLING <br /> LING v n COnsPLIgNCE 4 OWLEDCNEYT [ th d -ned Applicant,certify that I am the 0oner,OPnaroA or Awhorizeddgw of this Business,and I aclarowledge that all <br /> OMIT FEES. PEMLTTES, E,VFORCE.NENT CHARGES and/or HDVRLy CHARGES associated with this operation will be billed to me at the address identified above as the.{CCOUNT <br /> DRESS for this site. I also Certify that all information provided on this application is true and correct and that all regulated activities will he performed in accordance with all <br /> dicable SANJOAQVW COUYTY Ordinance Codes and/or Standards and STATE and/or FEDERAL Laws and Regulations. .0 the undenigmed owner,operator,or agent of the property <br /> red at the above HEALTH <br /> address, I hereby authorize the release of anv and all results and environmental assessment information to SAN JOAQUfI COU. <br /> VDdON�FENTaL FIEA[,T8 DfVISIOIY as soon it is available and at the same time it u provided to me or my representative. <br /> PLEASE PRINT <br /> PPLICANT NAME _ _.,t,✓ <br /> SIGNATURE � (`(. G <br /> ITLE DRIVER'S LICENSE# IJ <br /> /PHP TnrnP q I <br /> Accoauntin <br /> MY�VYCp ay #-'Qate 'fI <br /> v Offte Pro'Gessing COMplet d Ely Date <br />