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` Sam Jas u Ca Rubttc:;Hearth SlKrvfces .. etaIea# h3isl�t <br /> FORM (EH00i5(REw3e00817197) <br /> DATE MASTER FILE RECORD INFORMATION <br /> Sruroan Aal u F"END uf(gML+ UNIT IV <br /> -- - <br /> OMINER FILE <br /> COMPLETE THE FOLLOWING BUSINESS OWNER INFORMATION. cI+ECKIK REgCURRENTLrONFILEIWTHEHD El_......!.:.Ai............................. <br /> BUSINESS PHONE <br /> OWNER NAME `�----------------------------------------- <br /> F„ ' <br /> �r nt................ _.........tom(..._...................... <br /> has- a gni <br /> BUSINESS NAME(If diffinrsnt&-assn"OWner Name) (��! O t)�O 4 l7G Cooke _` : SOC SECT TAX ID E � GD <br /> ` tYTI ` ` 1� t.�` �IV A, � n n�.I r I��Qa-f 111 i <br /> OWNER NOME AOORE33 c t O� r, ^610N e' t 6'A a DRt — <br /> chv ��, `,'`A 1! fJ� l. STATE C A ZJP a p�—31 <br /> OWNER MAILING ADDRESS (if DIFFERENT burn OwnerAddnaes) Attention*or Care of (o tiwtaAV++ <br /> Mailing Address City 5 14 9 <br /> t Stats ' ' Zip " 7� <br /> CORpo"TtON INDIVIOUAL❑ PARTNERSHIP❑ LOCAL AGENCY❑ COUNTY AGENCY❑ STATE AGENCY❑ FED AGENCY❑ OTHER❑ <br /> FACILITY FILE <br /> AtaEsltTtflft: i <br /> F;�titTY:ifl.# <br /> COMPLETE THE FOLLOWING BUSINESS /FACILITY I SITE INFORMATION. <br /> Is Wi3 a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DIMION 7 YES ❑ NO X <br /> Is this an ExISTING Business LOCATION but a NEW TYPE of regulated Business 7 YES ❑ NO <br /> $USINE53IFACIUTY/SITE NAME R O 'Vpxrl,�;t .: 17 Go <br /> r <br /> SUITE# <br /> SITE ADDRESS BUSINESS PHONE <br /> _ a C'5 <br /> 3G S 63 <br /> Cllr � `/ A � STATE A i LP <br /> Mailing Address WDIFFERENTfirmFacilityAddress Attentive*or Car1db <br /> nRUa�? <br /> O <br /> S FJ C' <br /> Mailing Address City STATE C ZIP ( 1/� O <br /> N�OCA A 1 7 <br /> THIRD PARTY BILLING INFORMATION: COMPIGteif Billing Party is different from Business Owner Identiried above. <br /> ............................................................................................ ... .....................................................................................I................. ..................................................... <br /> BUSINESS NAME Attention'or Care Of (Opobna/) <br /> Mailing Address PHONE <br /> CITY STATE 71P <br /> g (ZUNT ADORE$$ for fees and charges36; ER FACIL(TWBUSINESS THIRD PARTY BiLUNG <br /> A«Lj,Nr SND COMPLIANCE ACICHOWLEDGNEYr: I,the undersigned Applicant,certify that 1 am the Owner,Operator,or Authorized Agent of this Business,and I acimowledge that all <br /> PEp,vir FEES, PENALTTPs. EIvFORCEMENr CHARGES and/or HOURLY CHARGES associated with this operation will be billed to me at the address identified above as the A coL'� <br /> .•uDDRESS for this site. 1 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 JOAQVIN 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 facilityhite address, I hereby authorize the release of any and all results and environmental ass i OAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DIVISION as soon as it is available and at the same time it is provided to me or my representativt <br /> PLEASE PRINT I <br /> APPLICANT NAME Q�+JI t,t SIGNATURE <br /> TITLE fN `N�,r DRIVER'S LICENSE <br /> ` l Qwnrnenor n�e�naFel <br /> ved gy t}aLEr lRaotg tlHtae frto�ieas <br /> is <br /> /_11616 <br /> cU f <br />