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�� V s:.aH.:;:w,nr< .P:'•F., <br /> • 'w:,r'e" .,s iJd'YYlitxiT ; y�' .Ftf Li#i/ � <br /> aYz�'aRo+�9.Syv>� S <br /> FORM (EN ip15(Rtivteeo DeHllaT) <br /> DATE I 2 / MASTER FILE RECORD INFORMATION <br /> IV�� UNIT <br /> 9 OWNER FILE UW 05'7 3 <br /> COMPLETETHEFOLLOW/NG BUSINESS OWNER INFORMATION' CHEcx/F OWNER CUM Mn:rONRLEMMEHO <br /> PHONE <br /> BUSINESS <br /> - J—sc—>—�.�_�r_�_��____———__——_——_< <br /> OWNER NAME <br /> BUSINESS NAME(if di ftxent boram <br /> OW114er Nae) i $OC SECI TAg 10 i <br /> DRIVERS UCENSEs <br /> OWNER HOME ADDRESS <br /> City i STATE i ZIP <br /> OWNER MMUNG ADDRESS (if OfFFERENT,i.,,o Der Address) ZIP <br /> i ACention:OrCaro of (OpbOrb/) <br /> Mailing Address City Slate <br /> CORPORATION❑ INDIVIDUAL D PARTNERSHIP❑ LOCAL AGENCY❑ COUNTY AGENCY❑ STATE AGENCY❑ FED AGENCY❑ OTHER <br /> 13 <br /> FACILITY FILE <br /> t;K�m� '';r'�z�„" �'� <br /> COMPLETE THE FOLLOW/NG BUSINESS / FACILITY/SITE INFORMATfOM <br /> Is this a NEW Business LOCATION not PreVIOUSly regUlatHd by the ENVIRONMENTAL HEALTH OMSION T Y6 ❑ NO <br /> I this an EXISTING Business LOCATION bUt a NEW TfPE Of regulated Business 7 YES 11 NO 13 <br /> BUSINESS/FACILITY/SITE NAME <br /> BUSINESS PHONE <br /> SITE ADDRESS �W00 <br /> SUITE S <br /> CITY /e_ ICS S SyATFh [ LP <br /> Mailing Address ifolFFERENTf,m Faddy Address : ACenben'Or Cann Of(Op00/+a/) <br /> STATE ZIP <br /> Mailing Address CitY _ <br /> . CDOG•,; :..� ., ANf4.fF• <br /> THIRD PARTY BILLING INFORMATION: Complete ff Billing Party is different froMBusiness Owner Idenbfledabove- <br /> Attention: <br /> BUSINESS NAME : nxcare or (opfiDnadJ <br /> Mailing Address ( t7"o o € <br /> PHONE <br /> CITYSTNr[ 0( <br /> '0 <br /> Ar-rouATAOnRFss for fees and charges OWNER FACLL ITY/BUSINESS Tmm PARTY BLLiNG <br /> BlLLINqe ANO COMPLLANCv ACIOy EPC, P , I.the undersigned Applicant,certify that I am the Owwer,Operator,or Astdnori:aAgeat ofthis Brain,and I 2CIGNI ledge that ail <br /> PzxjaT FEST, PZMALTITS, ENFORCEMIENT CHARGES and/or HOVRLT CILIRGP asseei eed with this operation mil be billed to me A the address identified above as the ACCOf/NT <br /> ADDRESS for this site. I also ratify that all information provided on this application is true and corrects and that erg regulated activities will be performed in accordance with all <br /> applicable SAN JOAQUIN COUNTY Ordinance Codes and/or Standards and STAn andfor FtDi R Laws and Regulations As the undersigned owner,operator,or agent of the property <br /> looted at the above facility/site address, I hereby authorize the release of arty and all results and environments] assessment information to SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DIVISION as soon as it is available and at the same time it is provided In me or my representative <br /> PLEASE PRINT <br /> APPLICANT NAME SIGNATURE <br /> DRIVER'S LICENSE 0 <br /> TITLE PA_-..,. =ns <br />