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......... .... .............. <br /> ................ <br /> . . ............ <br /> ab q I'" <br /> 8WJ <br /> 0a <br /> FORM (EHOO15JREVISEDW11119T) <br /> DATE MASTER FILE RECORD INFORMATION <br /> UNIT IV <br /> SMAOEDAR�FOR 9HO IIIIEO ...... <br /> OWNER FILE CHECKIP OWNER CURRENTLYONFILE WTHEHO <br /> COMPLETETHEFOLLowltil;BUSINESS OWNER INFORAfATION: <br /> .......................................................................................................................................................................................................................................................................................................... <br /> BUSINESS <br /> P <br /> HONE� <br /> NE�OWNER NAME ____________________—_____________—.......J <br /> -------------------- <br /> ...........................Ali............................ Olt <br /> ...................................................................J�,A(............ ................... ............... <br /> BUSINESS NAME(if different from Owner Name) SOC SEC/TAX I0# <br /> OWNER HOME ADDRESS 31 P4 <br /> city S+Z(_ F� STATE/' zip 6 <br /> L� <br /> OWNER MAILING ADDRESS (jfD1FFERENTfrom,0vr,;erAddrese;) w Attention:orCare of (OPtionail) <br /> Mailing Address City State ZjP <br /> F�F <br /> CORPORATION <br /> 'SHIP- <br /> IE3 0 nINDIVIDUALC] PARTNERSHIP 13 LOCAL AGENCY 0 COUNTY AGENCY 0 STATE AGENCY 13 FED AGENCY 0 OTHER <br /> FACILITY FILE <br /> 40—- , <br /> ..... .. .. . ... <br /> .4.. . ...... . <br /> ..... <br /> COMPLETE THE FOLLOWING BUSINESS FACILITY I SITE INFORMATION. <br /> Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DIVISION YES 0 NO <br /> Is this an EXISTING Business LOCATION but a NEW TYPE of regulated Business? YES El No Ik/ <br /> BUSINESSIFACIUTYISITE NAME <br /> SITE ADDRESS SUITE# I BUSINESS PHONE <br /> CITY STATti <br /> LP <br /> 2L <br /> Mailing Address if DIFFEREN T from Facility Address Attention:or Care Of(options/) <br /> Mailing Address City STATE I zip <br /> ......... <br /> THIRD PARTY BILLING INFORMATION: Complete if Billing Party is different from BUsiness Owner Idendfled above. <br /> ........................................................................................................................................................................................... .....................*............. ................ ....... <br /> Attention:orCare,Of (optional) <br /> BUSINESS NAME <br /> PHON <br /> Mailing Address Eb_�A -?93 <br /> zip <br /> CITY <br /> _T SQ n <br /> for fees and charges OWNER FACILfTY/BUSINESS THIRD PARTY BILLING <br /> BILLNC.ANDCOMPLIANCE ACKNOWLEDGMENT: I,the undersigned Applicant,certify that I am the 0"",Operator,or Authorized Agent of this Business,and I acknowledge that all <br /> PE&tf[T FEES, PENALTIES, ENFORcE1&N7CflARl S and/or HouRty CHARGES associated with this operation will be billed to me at the address identified above as the ACCOUNT <br /> ADDRESS 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 all <br /> applicable SANJOAQIJIN CO"TY 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 facility/site address, I hereby authorize the release of any and all results and environmental assessment information to SAN JOAQUTN COUNTY <br /> ENVIRONMENTAL HEALTH DIVISION as soon as it is available and at the same time it is provided to me or my representative. <br /> PLEASE PRINT <br /> APPLICANTNAME SIGNATURE <br /> DRIVER'S LICENSE# <br /> TITLE Az� (PHQTQ(!nPY 1117CHURPT11 <br /> Approved <br /> ......... <br />