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08/04/99 WED 10:21 FAX 510 663 4141 GEOMATRIX OAKLAND Z003 <br /> t.71-1 V <br /> � San Joaquin County alalic Health Services Environmental Aealth Division <br /> ,{�/d�� <br /> 11rr��P� rORM (EH00131MrY1Sran1Y71tAr}/ DATE 'S MASTER FILE RECORD INFORMATION <br /> `` 11,"Co.+r.+1.oRElie yeet)•K OWN"100 CAaeI 11 UNIT 1V <br /> OYYNER FILE <br /> COMPCE7ETHE FOLLOWING BUSINESS OWNER INFORMATION: CHfCNae OWNER CURRENTLrONflLfYy/rNEHO <br /> ......................................................... ^....,..........- ............................,...........................-...._..........._........................................................-.......-............................................... <br /> OWNER NAME __---�---y __— <br /> .....F?r .................N!.......,.....--....`.......- ............i+al...............................------ <br /> BUSINE33 NAME(If different Fvm Owner Name) /�. t +[ -' SOC SEC/TAX 10 K <br /> pwwcn HOME AOORES3 / 4I !a U rjrr£££JJJwww OnIVFR's LJCt.Nst'1f <br /> Cny �Tt7 (.L/ /� ' STATE Zi/ zlp <br /> OtnNER MAILING AD/DRRE33 (ifOIIFFERENT Brom OwererAddrar") Attention;orC.we of (opdanall <br /> Mailing Address City State zip <br /> ConroRATION❑ INDIVIDUAL❑ PARTNERSHIP❑ LOCAL AGENCY COUNTY AGENCY❑ STATE AGENCY Q FE0 AGENCY 0 OTHER❑ <br /> FA iLITY FILE <br /> FArniTr 10x' s;ROJa REs II!R AecotntT to If 1 t <br /> COMPCETFTHEFOLLOWING BUSINESS I FACILITY I SITE INFoaaf rioN: <br /> Is this a NEW Business LoeATION not previously regulated by the ENVIRONMENTAL HEALTH 01101310"? YES ❑ No ❑ <br /> Is this aft EXISTING Business LOCATION but?NCw TYPE of regulated Buaintrss 7 YEs ❑ No ❑ <br /> BUSINEss(FACILITY/SITE NAME r _/ �+ `+� / ! ' <br /> SITE AODRess �^` Imo✓G�: II SUITE 0 BUSINESS PHONE <br /> CITY ;,� / sYylt:� Lp <br /> Mailing Address dGIFFERENTIivro Faci"yAcWts" Attention:or Care Of(optional/ <br /> Mailing Address City STAYS LP <br /> SIC GOOE /tPN b t�artsarrt <br /> THIRD PARTY BILLING INFORMATION: Complete if Billing Party is different from Business Owner Identirted above. <br /> ..............................:.......................................................................................................................................................................................................................................................................... <br /> OU311ilf",NAME Attention:oeCare Of (opdJanAl) <br /> Mail"Address PHONE <br /> CITY STATE LP <br /> 9F,F0VNLAaLV[M for fees and charges OWNER FACII,ITYIBVSINESS THIRD PARTY B WNG <br /> 1 1 C,ter r0 IPI 1 t'r %c Kr4OWLEDGs1t74T; 1,the undersigned Applicant,certify that 1 am the 0*ww".Orrrar e.nr.4aihvn,;ed.Igmd of this Busmt%s.aml I scknnwledEe that ail <br /> Pk,-aAfir FEES. mvnneT. FNFORCE•iIFM ClLIRGES andlor NOURb1'GuRcCe a+sticraied with this operation wall be halted in me xi the xddrn+identified above :u the l rrnnvr <br /> IhliRE.sS tor lhr++ar- 1 J"eeniry that all information provided an this xpplieation ie erne and correct; and that all reg,dated activities will he performed in srrontxncr 1riih Al <br /> 3pplicxhlr SAN,IOAOUIN C,jLNTY Ordinance('tnlrn andlnr Standards and STATE rnd/or I'rpFRAt.Law+And Retulathmi. V the undrnigned owner,upmuw,ur a>;rnt nt,hr prnpem' <br /> locnied A the alh)ve WilitvNitr addnn+. I hereby ADthonze ,he release ar any and all resuils and envuonmeniai weasirwat Inrormatiun ut SAN .00A011iN C()UIv I l' <br /> FN VIRONMENTAL IiEALTII DIVISION as soon n it Is available and AI the%&me time it is provided to me or my reprt:rnta(ive. <br /> APPLICANT NAME SIGNATUR <br /> DRIVER'S LICENSE d <br /> TITLE <br /> IVNnTnCn DY OCOtfIDFnI <br /> Approved By Osla Acowutting Office Processing Completed By Date <br />