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:=Saii:Joa e�IrxCou _ itfdea[t. .I fn�lrOn aCw <71u�s�oT <br /> l- FORM (EH 015(11 v1 ti]J 7) <br /> ,DATE ��Ifl '� MASTER FILE RECOR7 INFORMATION <br /> SHADED EHD n �``E,W„ ,o UNIT IV <br /> OWNER FILE" "" <br /> COMPLETETHEFoLlow/NG BUSINESS OWNER INFORMAT/ON." CNfcarF OWNER CuaRENnroNFicewanEHO� <br /> ........................................................................................................_....... <br /> BUSINESS <br /> PHONE <br /> ------------------ __ _ ( ( y <br /> -3'a1OWNER NAME S <br /> ...................................................................eraf........................................Nl......._.......................................GArt......................................: <br /> BUSINESS NAME(if different front Owner Nam@I�/.�.�_� //;�,3� 1 , ,/ SOC$EC/TA%ID# <br /> !' OWNER HOME ADDRESSI���t/ �`^ aT[J DRIVER'S LICENSE <br /> City STAT ZIP ?,97 C ^7 <br /> f <br /> OWNER MAILING ADDRESS (WD/FFERENTntOwnerAddress) Attention:orCare of /options/J GX/ <br /> Mailing Address City 5,157 ��U I ,r /2�L j o State <br /> CORPORATON❑ INDIVIDUA PARTNERSHIP❑ LOCALAGENCY❑ COUNTY AGENCY❑ STATE AGENCY❑ FED AGENCY❑ OTHER❑ <br /> FACILITY FILE <br /> COMPLETE THEFOLLOwlw BUSINESS/FACILITY/SITE INFORMARom- <br /> Is this a NEW Business LOCATION not Previously regulated by the ENVIRONMENTAL HEALTH DIVISION? YES ❑ NO r!r <br /> Is this an EXISTING Business LOCATION but a NEW TYPE of regulated Business 7 YES No p <br /> BUSINESS/FACILITY/SITE NAME <br /> SITE ADDRESS p SUITE# BUSINESS PHONE <br /> to2,Z <br /> X73a / <br /> CITYS�TE ZIP q <br /> l�_ <br /> neonopsupErrvian& n"., t's,»amr r - Y4 <br /> Mailing Address ifDIFFERENT from <br /> 'Flaci/ify Address 1 I Attention:or Care Of(optionna/J <br /> Mailing Address City5 "J / C�{�,2P e/L S'�'DlrpA..�,. ' STAFs„ b ZOiP�C �—f <br /> a + <br /> Fli <br /> THIRD PARTY BILLING INFORMATION: Complete if Billing Party is differentf-om Business Owner/dented above. <br /> .......................................................................................................................................................................................................................................................................................... ... ....: <br /> ! BUSINESS NAME / ^ ! Attention:orCare Of (Optional) <br /> Mailing Address L/rLI L PHONE <br /> CITY STATE ZIP <br /> AccouNTADDaess for fees and charges OWNER FACILITY/BUSINESS THIRD PARTY BILLING <br /> BILLING AND COWLIANCE AOI OWLEDGMENTI I,the undersigned Applicant,certify that I am the Owna,Operator or AWNorized Agent of this Business,and 1 acknowledge that all <br /> PEmG-FEES,PEVALTm,ENFoRcE EATCHAgc; s and/or HOURLYCHARCFS associated with this operation will be billed tome at the address identified above as the ACCOUNT ADDRE45' <br /> for this site. I also certify that all information provided on this application is true and correct:and that all regulated activities will be performed in accordance with ail applicable SAN <br /> JOAQUIN COUNTY Ordinance Codes and/or Standards and STATE and/or FEDERAL taws and Regulations. As the undersigned owner,operator,or agent of the property located at the <br /> above facility/site address, I hereby authorize the release of any and all results and environmental assessment information to SAN JOAQUIN COUNTY ENVIRONMENTAL <br /> HEALTH DIVISION as soon as its available and at the same time it is provided to me or my representative ` ol/� <br /> PLEASE PRINT V C�✓ ^'�✓ <br /> APPLICANT NAME l��. SIGNATURE _ <br /> �q p,^—r '�j ��i�f.�'��$' DRIVER'S LICENSE <br /> TITLE # _ <br /> F� . " 1PNOTOI:nPV RFO111RFR1 <br /> ..Approved-By.;` c ,-= Date " `, _d � ``. 'l e�epibiting"ORfceProceeatr Come gY •�- <br />