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fa' <br /> S"s "05-50i2 Dun I• ealt: e ice EnuHrontnenta eal`t�`d vl Is o <br /> DATE1 11 MASTER FILE RECORD INFORMATION FORM (EH0015(REvIseD072319>) <br /> SXAOEa..WFOREHDUOEONR N�i1D UNIT <br /> '" <br /> OWNER FILE v'Y V <br /> , �COMPLETETHEFol LOWING BUSINESS OWNER INFORMATION: CHEcRIF OWNER CURRENrzyONFILE wirHEHD <br /> 4:................................................................_----- _..._.........._......__..................T........._...._....._ .........._._--------------_------------------------_._......_--_...__T............. <br /> BUSINESS I 1 11 0 1,,•1 PHONE <br /> '. ' OWNER NAME _e_c-�J_`___�_____�rLy=Y��_________- i <br /> ....................... <br /> ............................................F.rA.................__._........_.....M.................,..._..................0ut................................_..... <br /> ' <br /> ffi <br /> ;y' BUSINESS NAME(d different from Owner Name) i Soo SECTTAx ID III <br /> OWNER HOME ADDRESS �. C� `}-� <br /> ��O DRIVER'S LICENSE# <br /> city <br /> Loa �A q,5a�{o <br /> STATE Z P <br /> na <br /> OWNER MAILING ADDRESS (WDIFFERENTfrom Owner Address) [ Attention:orCare of (optional) <br /> Mailing Address City State ' Zip <br /> is <br /> r CORPORATION❑ INDIVIDUAL❑ PARTNERSHIP❑ LOCAL AGENCY❑ COUNTY AGENCY❑ STATE AGENCY❑ FED AGENCY❑ OTHER❑ <br /> F GU 1 FACILITY FILE <br /> ar ±�tt��vrw� ro., L� ..;.. <br /> ,-.CR,Osss R�ID.#s: .mm fr�'`/lccouNrlD`- " .,°!; *.. t._, <br /> COMPLETETHEFOLLOW/NG BUSINESS / FACILITY/SITE INFORMAT/ON.- <br /> Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DIVISION'] YES ❑ NO ❑ <br /> Is this an ExISTING Business LOCATION but a New TYPE of regulated Business 7 YES ❑ No ❑ <br /> BUSINESSIFACILITY/SITENAME Ctfi� •� � 1 _ �1 — 11���� ^ � �ecrea't��an <br /> $ITE AODREss 1`•"I 1 o Il../V\ 1' u $UfTE# i BUSINESS PHONE <br /> 17 F. ELY" ST an� 0101 C. LOCUS <br /> ClY <br /> Sn Lv 5,R <br /> Mailing Address if DIFFERENT from Facility Address + Attention:or Care Of(opG'anal) <br /> Mailing Address City ` STATE : ZIP <br /> 'z!2'.�S'h- ' �Tl+s'Me �. -. g „�'M � , � ,� i•- x�. �..r 'v i i*aax <br /> THIRD PARTY BILLING INFORMATION: Complete if Billing Party is different from Business Owner IdenbWedabove. <br /> _.............................................................................._................_...._. .._...._.......... ..._...................._...... _ ..........._._.............. <br /> i BUSINESS NAME t ; Attention:or Care Of (optional) <br /> art s a Recr. <br /> Mailing Address PHONE <br /> CITY I _J J 1 1. rtJ [ STATe` ZIP O 5a V(D <br /> ACCOUNTADORESS for fees and charges OWNER FACILITY/BUSINESS THIRDtPPARTY BILLING r <br /> BELLING AND COMPLIANCE ACILNOWLEDGMENT. 1,the undersigned Applicant'certify that 1 am the Avner,Operator,or Authori.edAgod of this Business,and I acknowledge that all <br /> PERMn'FFES,PENALTIES,ENFORCEMEVT CHARGES and/or 1[017 Ly CHARGES associated with this operation will be billed tome at the address itientified above as the.4 CCOUNTADDkM <br /> for this site. I also certify that sll information provided on this applimtion is Me and correct;and that all regulated activities will be performed in accordance with all applicable SAN <br /> JOAQUIN COUNTY Ordinance Coda 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 /> 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 it is available and at the same time it is provided to me or my representative. <br /> // n PLEASE PRINT r ,I <br />-' APPLICANT NAME �� SIGNATURE �_ /✓✓� <br /> i <br /> TITLE F _ DRIVER'S LICENSE# <br /> (PHOTOPOPYRrOInRFn1 <br /> pfovtad BYE''.. tr"Da g:Acb"""eount7ng Offtce Frocess'•' 'ngo p eted'. Dat'etr. v z- �., <br />