|
111..14/'2000 1 f:0b 2i3y4683433 FIFTH FLOOR WAGE 03
<br /> • ;,i..>:. ;yro-<••^[:S;f.; .n <:r' '�G `f":i".::,i''.wf.��+�^-alw-1�.�t<:s»r�ktrro<r...N.a:f:�l'$.;y_2 's3:) '/�+�Ri[.�":,'d✓�IX s-4m"'xe?s�d xf.��..
<br /> r� vk h O'+�<�TW.i. � '$ i:►441� F'i: vs '����uuss tF,te.;,�:7���Ar• 1 .s :. ,. '.w:1;,.,, A.,... 0 .I:.:., s....x.a .......
<br /> .,s, y ,,.....«•. ...� s- WRM (Et1001548151REvufo06n1s97)
<br /> DATE i
<br /> i,L/ MASTER FILE RECORD INFORMATION
<br /> 1 c IT IV
<br /> OWNER FILE
<br /> CHECK/F OWNER CURREM'c r orr TILE wrrrr EH D
<br /> US
<br /> FOLLQNI'/N�s BINESS OWNER /NFORINAT/ON.
<br /> :OMPLETE THE ........... _._--. ---- •• •• --— - -- -
<br /> L... —«.-. B ......WS O —Pte.......---N• .._.......--....._--._.......__-...... -— PHONE
<br /> BtrSINES3 / /uI / �(��l / L RRA lIG> LZ�� __________ ---
<br /> OwNER NAME —N LCL►l_—
<br /> ...•... ....._....-.- Soc SEC/TAX ID C
<br /> BUSINESS NAME(if di/fOr-1lhaoOwner'Name)
<br /> _ r DRIVER`SUGENSEC
<br /> OWNER HOME AOCRESS
<br /> CItY 'Y C : STATE'-4 ZIPS—
<br /> �
<br /> ONMER MAIIJNCADDRE9S (IfCIFFFRENTfrom OIYr'Brq�ldreasJ
<br /> AtLantion: or Care of (optiar:,/1
<br /> Stats ZP
<br /> Mailing Address City
<br /> CORPORATION❑ INDIVIOUAI❑ PARTNERSHIP❑ LOCAL AGENCY I❑ COUN'TY AGENCY❑ STATE AGENCY❑
<br /> FED AOENC'r O OTHER❑
<br /> FACILITY FILE
<br /> .;.,....• :
<br /> i>ay;-'i".".2:2:3<t +s e•.'�-�=Ns};il's< v ,:t2 r.;_� �A sr�)ssK:�we.y tee A>I' x; 2 < t u P.T,.Sd'
<br /> 1eE. 3Yb yR .e _> S < at I
<br /> 2Y s , d'`eq>Xy siTr� >Vtt#.i'3.
<br /> . es�L3F765 �:�Cl'fll�. .... . �.e+....�;s<�>g.fi'a'.y.'^•t ...
<br /> COBfpf RTE THEFOLI.owlArG BUSINESS I FACILITY I SITE INFORMAL"/DN. YES ❑ O
<br /> Is this a NEW 13usino53 LOCATION not Iartiviously regulated by ttic ENVIRONMENTAL HEALTH DIVISION YES ❑ NO ❑
<br /> Is this an EXISTING Business LOCATION but a NEwTrPI;of regulated 8uaines3 1
<br /> BUSLNESS/FACILITr/SITE NAME
<br /> ! SURE if BUSINESS PHONE
<br /> SITE AOORESS
<br /> STATE Zp
<br /> CI't'r t Ns°
<br /> >s: s 9 r ! i 2 ��.'�y •a',:sy s •sas,l' y y I s s s ?fri . a,G:.`4il:ysSu�N. .c:n2 y�.>i'sis
<br /> sf s k f •os s :.=ham. sl„<; t.; 'g�_ �..i sk xo'2'sf <. i. ;S .fd� *"s..
<br /> 3i`.s�f ;,
<br /> i <E s VSs 3 s > ••>.2r
<br /> r Attention:or Care Of(optional)
<br /> Mailing Address i/OIFFERENTfrorrr Facility Address
<br /> STATE 7sP
<br /> Maibng Address City 2.
<br /> >< < >c -.!ia i>: .. ,a;de .-°r!' 1 S'jx• s o �'� �Z"”'sy`0`I � t�'3<�'F �'et�S
<br /> ..: v 2 ;s�ss!9 pr3i o I � :"°<s r t .`� 4 rst'�'i' !"' t�� � m>2 ��4. r>f>:el., �je3aS��f '�,yk �4 2.s'j }.e� .. ..e r..,.. S s.s...:. °.i,<s N'.k<des$J•. � ..
<br /> >:: r osxL< 2 r �rl�It £ s 1 y��S» ..et���j�..,<.sf• uX,`S�¢�:fd:. 1..�.�s: .� .,c•: `.i;c��'•z..e;.� �' rvaj;,�,r �i'?9T'...'r� ..
<br /> THIRD PARTYlBll.L1NG INFORMATIVN� Com Tete rf Sillin Party rs difierentfrom•Business_Owner/dentjfiedsbv✓e ..�^
<br /> S
<br /> P - -
<br /> ..........._.............__.........---..........---.........-._....�.... p n:or Care Of (oFGwryQ
<br /> BUSINESS NAME�� /�� t �0
<br /> PHONE (4110Mailing Address
<br /> STAT Zip
<br /> Cm
<br /> LU2SFS far fees and charges
<br /> OWNER FACILITY1BUSINEss THIRD PARTY BILIJNG
<br /> llcant,cern 'hat I wn the Owner,operator,or e4atierited A;&W of this Boeiness.and I ac wtedpe that'd
<br /> BIL [arr tN COMPLIANCE ACtclewLstx.rE�tT; 1,the undersigned ApQ fY
<br /> AeCaEwr
<br /> pgl A&r FeBS. Patw!•rr= VA701tCa:wZNT CrLIRGTS and/or 110URLIr CMRCEe associated 'dam tb"° 1O1c Mt0 be billed to me at the address Identified above a9 ;he a with
<br /> ln` DRQ for this lite 1 �w certify thot all information provided on (his application is true and correct: and that all regulated activities will be perfonncd in accordance with pert'.
<br /> applicable SAN JOAQULY COUNTY Ordinance Codex andlor Standards and STATE and/or FEDEtt tL Laws and Regulations. .0�e undersigned ownc[,oPerat°r•or a; `'INOftCOUYI N
<br /> located at the above faci'W
<br /> Pk addnss. I hereby authorize the release of anyand Ill caalts and environmen��t21 cement infonaa[ioo to $.a2`l .fOAQ
<br /> E,'NVUZ0 NNMjVTaL HEALTH DIVISION as soon u it is available and at the same time it is provided to me or my rcpres
<br /> P"Ase PRINT
<br /> Ck SIGNATUR�-
<br /> APPLICANT NAME � f rh fj
<br /> ` DRIVER s LICENSE>r L ?yiiq'7
<br /> TITLE `O s s sY <«.�i'<•:i ivy
<br /> ,.� i:•r,..r.'::>.t^.a:�:.>;::a::vs„s:fid; 4> .. da8�i
<br /> :. t w s i "i• k 3• �>S',A,j y{.. R• s.)
<br /> hC}(II'ovec�tti)t`< f; f ` .k yzY"' �<�LeE;%' :>;:`,<vf;i:l!`.'s�s,su. r/ltt7�iififn43��e'�smCSsmr'iog:Co[f2;Y�'e
<br /> 1
<br />
|