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�.. ...— _. ,....._ �...n. .,. ..��..,.nv�q„y. .fin rf„^w r •-'�-...._. .y.. . _ <br /> ..�:.,;:' . . =San°Jo'a um Coun ubirc-H_e_alt,Services._ Environm �H`ea�tDlvrst�ns , _�sre <br /> DATE ���/� �'-�� TER FILE RECORD INFORMAT FORM (FJI0015(RevaEO072397) <br /> SMAOEa AXFAD FOa END II]EO DWNEtrIDfr:'.' +•�^^"�°- �� U�'� 'V <br /> OWNER FILE <br /> COMPLETE THEFOLLOW/NG BUSINESS OWNER INFORMATION: CHECKIF OWNER CURREATLroVFjLE nn+EHD� <br /> ..........................................�.—{.........II..................---'--.----....................._.................,......................................................_................_.............._................................................................... <br /> ......_._. <br /> BUSINESS PHONE <br /> OWNER NAME <br /> .................................................._...............F.rat................_............._.......ML.............._....._......................Mt...... <br /> ....._................._.__'• <br /> BUSINESS NAME(rt different Irom Owner Name)il 7Z i SOC SEC 1 TAX ID# <br /> 4yDOWNER HOME ADDRESS[ L:(�r 77/'_. I (7'// A� I DRIVER'S LICENSE# <br /> city 7 d7 Gam'Ary/� LP <br /> OWNER MAIUNGAOORESS (iVDIFFERENTfroin Owner Address) Attention:orC igo�f-(rapUona/J _/S <br /> Mailing Address City State-Sq �tW� � <br /> CORPORATION❑ INOIVIOUA PARTNERSHIP LOCALAGENCY❑ COUNTY AGENCY STATE AGENCY FED AGENCY OTHER❑ <br /> FACILITY FILE <br /> ,FAclu'rciD#R ,. .,:r-T '.rCRossREr:Ifl firs?9.x. ;Ac N7e1� ::«i WW, N ? .1�`g"�."',:. <br /> COMPLETETHEFOLLOW/NG BUSINESS 1 FACILITY/SITE INFORMATION.' <br /> Is this a New Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DIWSION? YES ❑ 141010� <br /> Is this an EXISTING Business LOCATION but a NEW TYPE of regulated Business? YES NO ❑ <br /> BUSINESS/FACIUTY/SITE NAME <br /> SITE ADDRESS I1'/llT/Y/-fifl�V� n ! SUITE ( BUsINEss PHONE <br /> tom N M`7(it l0 S� �73-2�6a I <br /> Cm C � i/ STATE I ZIP +�� <br /> �5�- 2D5 <br /> Mailing Address IfD/FFERENTfrom Faci/ityAddress Attention:or Care Of optionaq <br /> Mailing Address City '5Y'5 '7 /_� �r'E-fie` S-� „ / ST! jC i zip <br /> .SIC CODE - 'AEN# LIAM <br /> THIRD PARTY BILLING INFORMATION: Complete if Billing Party is.diferentfromBusiness Owner Idendf/edabove. <br /> ..............................._............................................_......_._.._............_.....__......__.................................................._.__._....._....._._.................................................................................... <br /> __ <br /> BUSINESS NAME A ' /� ? Attention:or Care Of (opfiona/) <br /> Mailing Address /v l PHONE <br /> CITY STATE ZIP <br /> ACCOONTADDRESS for fees and charges OWNER FACILITY/BUSINESS THIRD PARTY BILLING <br /> 3tLL1NG AND COWLtANCE ACTGNOWLEDGMENT: I,the undersigned ApplicamL certify that I am the Owner,Operator,or Authorized Agent of this Business,and I acknowledge that all <br /> aFRMT FEES,PFNALHTE4,ENFORCENEvr CHHAfGPY and/or HOURLY CHARGES associated with this operation will be billed tome at the address identified above as the ACCOUNTADORE4 <br /> 'or this site. I also certify that all information provided on this application is true and erect;and that all regulated activities Will be performed in accordance with all appliobk SAN <br /> IoAQm COUNTY Ordivance Codes and/or Standards and STATE and/or FEDERAL Laws and Regulations. As the undersigned owner,operator,or agent of the property located at the <br /> Ibove facility/site address, I hereby authorize the release of any and all mutts and enviroomental assessment informant.. to SAN JOAQUIN C,O/U`fTYY ENVIRONMENTAL <br /> 4EALTH DIVISION as soon as it is available and at the same time it is provided to me or my representative. <br /> _ <br /> PLEASE PRINT <br /> APPLICANTNAMEyUILE41,1 . <br /> SIGNATURE - <br /> TITLE �G _ .�� lis DRIVER'S LICENSE# _ <br /> Approved By .. - Oate , '-+F'%° sAieoUntlnO Office Processing Comofeted BY.. '�. ""Ns:w.. Dets•.. 3 -�a,sh�:x^ �::,."` <br />