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r <br /> San `%q,uin County Environmental He.,attr n?epartment <br /> ORPE N FORM, <br /> DATE MASTER FILE RECORD INFORMATION "�1�'IFR" <br /> G.1sn.n..e.,w FNn�es ntwv ' <br /> OWNER ID# t ` _.. CASE# ...... J u ty 1 7 "IT IV <br /> OWNER FILE <br /> COMPLETE THEFOL\LOWINGPROPERTY OWNER INFORMATION; CnEaCIF Owpir�IRtthri� .,, EHD <br /> PROPERTY OWNER ' ,v��� /I p � PHONE J <br /> NAME ,✓ J fV'Q'. 2U <br /> First Ml last <br /> BUSINESS NAME ��� „ A A _ !� _ SOC SEC/TAX ID# <br /> Owner Home Address © iS t/ / 2 L DRivER's LICENSE# <br /> City V 7` (,� T STATE 11,/,__ zip aj�Z C5 <br /> Owner Mailing Address CA <br /> - <br /> Owner <br /> Address City may„� � te staZip <br /> F nDN <br /> 7VW rd: -'�C..l <br /> r'noonoerrnN 6� TNnMn11A1 ❑ DADTNFDWiD❑ rFn Ar_FNI'Y❑ riT}IFD❑ <br /> FAeltm ID# %f'1 I' l CROs RV ID# ACCOUNT ID# INK# <br /> ��� �`�I�d <br /> '1 s.+'.CJ�'� L..i`, <br /> COMPLETE N <br /> Is this a NEW Business LOCATION not previously regulated by the ENviRoNMENTAL HEALTH DEPARTMENT? YES ❑ No <br /> Is this an E:asnNG Business LOCATION but as NEw TYPE of regulated Business? YES ❑ No <br /> BUSINESS/FACILITY1SITEl��� <br /> SITE ADDRESS No 4?7�( �� SUITE# Vt1SINFSG p:p — <br /> CITY C� `J— 1 STATE ZIP �_jS76 <br /> I[ BOARD OF SUJPERV[sOR DISTRICTI�f/�'JIVi LOCATION CODE t KEY1 K-2 t./s) �I <br /> Mailing Address WDIFFERENT from Facility Address t Attention:or Care Of(optional) <br /> Mailing Address City STATE ZIP <br /> �cAPN# (bMMENT: <br /> THIRD PARTY BILLING INFO: Complete if Billing Party is different from Property Owner or Facility Operator identified above. <br /> BUSINESSAME Attention:or Care Of (opb'Onal) <br /> �l G`�� S7CDC 1TJx1 N�cC_S/�clC / ��ti' c71 Ki <br /> Mailing Address PHONE Q q�7 AF <br /> CITY �-�r`���r Y.-rM � , / 1'rn 1 STATE � /{[[ ZIP!! <br /> drYr�umr ennLaT cCK� <br /> for fees and charges OWNER! FACILITY/RuSINESS / BILLING <br /> � ! <br /> RILLINr]ANn rompi.IANCK AcKNnwi.RnQMKNT: 1,the undersigned Applicant,certify that 1 am the Owner,Operator,or Authorized Agent of this Business,and I acknowledge that all PERMIT FEES, <br /> PENALTIES,ENFORCEMENT CHARGES and/or HOURLY CHARGES associated with this operation will be billed tome at the address identified above as the ACCIWNT AnaxF_CC for this site. I also certify that all <br /> information provided on this application is true and correct;and that all regulated activities will be performed in accordance with all applicable SAN JOAQUIN COUNTY Ordinance Codes and/or <br /> Standards and STATE and/or FEDERAL.Laws and Regulations. As the undersigned owner,operator,or agent of the property located at the above facility/site address,I hereby authorize the release of <br /> any and all results and environmental assessment information to SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my representative. <br /> PLEASE PRINTAPPLICANT NAME ` ft"J ,K/ SIGNATURE <br /> (Z <br /> TITLE ,t " G DRIVER'S LICENSE# <br /> (PHOTOCOPY REOU <br /> Approved BY Date ACcounting Off.Processing Completed By' ,,1 Date <br />