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10/06/2001 13: 57 2094683433 FIFTH FLOOR PAGE 04
<br /> •> '' FORM IEH MI
<br /> OATS MASTER FILE RECORD INFORMATION
<br /> ,�w .rry,e^r,,,Fj+y.; rt+•r ac a7So. 1 `)' ,'uC w°. r.,v�'R�£ UNIT IV
<br /> Seeusoe 'vet—'�_2Etl4usr^,• vak�Ot4�'. �k Zi 1 '�+ a'3 ,'. �
<br /> • OWNER FILE
<br /> CHECKIF-OWNER CuRRENrGrONrILEtarNEHO,�
<br /> COMPLETE THE FOLLOWING BUSINESS OWNER INFORMATION: _ .._.......... ,
<br /> ................................I....,,......................,........__.......,._........—...._.:....................__.....I........_..........._...._.
<br /> PHONE
<br /> BDSINE48 i i
<br /> OWNER NAME _____________________�________�—____—_—___. CSS`t� S43 - ZI00
<br /> ......................�i[sA_.........._.... .....:!!!..._........................................l:±U...................,.............. [
<br /> ............................................. .........,..-.
<br /> i SOCSECITmtID#
<br /> BUSINESS NAME(IT dillartenT from Ownor Na'""') :
<br /> I Lt.('i�• r7 Q..IrLU F111:A1tyTt Oso I-'(�t.14 �Mf�r-tT i
<br /> OWNER NOME ADDRESS DRIVER'S LICENSE 10
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<br /> STATE ( : LP A O�Q�
<br /> OWNERMAIUNGADOnrss (if0fFFERENTfrom OrotserAddress) Atbentlan:or Care of foprion�q
<br /> Mailing Address City state LP
<br /> CORPORATION INDIVIDUAL❑ PARTNERSHIP LOCAL AGENCY❑ nO,1 f AGENOY0 STATEAGENCT❑ FED AGENCY OTHER❑
<br /> FACILITY FILE
<br /> a: G"sPM;v'+ia., ;a;y-car -%< �S•i><... ,,.w.., ,.5. _. , ' k'`Ftra ,` ..a: Pz
<br /> st .tT� -0501
<br /> COMPLETE THE FOLL OWING BUSINESS I FACILITY I SITE INFORMATION:
<br /> Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DIVISION? YES 0
<br /> IS Nis sn eosTING Business LOCATION buts NEW TYPE of regulated Business 7 YES O NO ➢fl
<br /> BUSINESWFACIUTYISITE NAME /�J •
<br /> SITE ADDRESS SUITE# BUSINESS PHONE
<br /> I q o4 v� C��•R—TE:e2 ww`f
<br /> CIT' STATE i ZIP
<br /> S•ro Cas--rol-1 �1 S 20(P
<br /> _ ti a.r . roe ,s- H: ":tR bY-.j3�•. 'E v,., v
<br /> Mailing Address ifD/FFERENTfrom FsefAfyilddres^ f Attention:dr Care Of(optiorrsl)
<br /> Mailing Address City STATE ZJP
<br /> Y� 'e•y
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<br /> THIRD PARTY BILLING INFORMATION: COmPlete if Billing Party /s different fromBUslness Owner Identified above
<br /> . .............................._._........................_.._....._._............. ...._..............................__...._..._...._.............__..,...............__...................
<br /> . BUSINESS NAME t Attention: orCars Of (op60-0
<br /> Mailing Address PHONE
<br /> ' CITY STATE LP
<br /> �ICGQLyIdDORE7_q for fees and charges OWNER FAciumBU51NEss THIRD PARTY BILLING
<br /> 13tLLna arvD COMPLIaNr.'P..ACTCtOwT,6oGMNT: 1,the undersitned.kpplican4 certify[hat I am the 0 v ,,,Opaaror,or,d)tdrori:ed Asenr of this Business,and I adawwledge that all
<br /> PCW1r FEES, PPVALTTES, E!vPORCEVEAT OPIWES and/or IfoVRLY CX,,Wss associated with this operation will be billed to me at the address identified above as the ACCOUNT
<br /> ADD R „Esc for this site. 1 also certify that all information provided on this application is true and correct;and that all re;ulated activities will he performed in accordance with all
<br /> applicable SAH JOAQUCI COUNTY Ordinance Codes andfor Standards and STATE sndlor FEDEILYL Laws and Regulations. As the undersiggo owner,operator,or agent of the property
<br /> located al (he above facll;ry/sits adeireao. I hereby authorize the release of any and all results and environmental assessor• ' formation to SAN JOAQUIN COUNTY
<br /> ENVIRONME`ITAL HEALTH DIVISION as noon as it is available and at the same lime it is provided to me or my repro edtative.
<br /> PLEASE PRINT
<br /> APPLICANT NAME �A2nD � �A•w2lot� J SICNAT
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<br /> C'�Ems-araTRltC 1��15•ac.Tta�sTL =NL. \ DRIVER'S` CEISE =��L
<br /> TITLE P?aEs .a Mt�1..�2- 'SPR S fEMEPIa+.TIOt-a •��T
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