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#:: Q �:::. QU#3 :::[::. DATE MASTER FILE RECORD INFORMATION FORM (EH 0015(REWSED 06ft 1 f97) SNADED A{E/N FO EH Y{E ONLY :i�'i�`Si::ii`::::?:`:i:::is2?::::)::::::i:v:i>:':'?::?i:, UNIT IV �� OWNER FILE 6��J1(RL EFOLLOkF/NG BUSINESS OWNER INFORMATION: CHECK/F OWNER CURRENTLYONF/LEiY/TNEHD n .................... .. .............................................................................................................................................................................................................................................................................. '+ i HONE BUSINESS P ^ ......OWNER NAME ---st — — 967 ..........................................................First.......................................Ml................................ .... ..... ........ ... BUSINESS NAME(If different room OWner Name) c/TAX ID# SS7-27 1O7q OC 5 OWNER HOME ADDRESS S ' P / ! DRIVER'S LICENSE# AJ 47,),S city 7 �1 ENVIRONMENTAL H T zip 15%& i 0"v, $E;PVI g2_ OWNER MAILING ADDRESS (if OIFFERENTfrom Owner Address) S�M ? ^� ^ Ov Attention:or Care of (opdonal) Mailing Address City i" ff /T ° State ° ZAP CORPORATION El INDIVIDUAL PARTNERSHIP❑ LOCAL AGENCY❑ COUNTY AGENCY❑ STATE AGENCY❑ FED AGENCY❑ OTHER❑ FACILITY FILE :::::.:::.:::::..:. .... ... COMPLETE THE FOLLOW/NG BUSINESS / FACILITY/ SITE/NFORMAT/ON: Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DIVISION? YES ❑ NO ❑ Is this an EXISTING Business LOCATION but a NEW TYPE of regulated Business? YES ❑ No ❑ BUSINESS/FACIUTY/SITE NAME y/ Pei jI SITE ADDRESS 1 SUITE# BUSINESS PHONE Cc�tot/,l � o CITY ��//`,'� �,� STNf$/� ZIP Mailing Address if DIFFERENT from Facility Address E Attention:or Care Of(optional) Mailing Address City STATE ZIP # `<':=<:::::::::: > >o �> >> :< '��»>'�3<< >< > . . �< -. ...... is �'>�..��......... CQD�............................. _ .. . THIRD PARTY BILLING INFORMATION: Complete if Billing Party is different from Business Owner Identified above. ........................................••----.......--------------...............................................................................------..................................,.----........................................------......---._..............................................., BUSINESS NAME Attention:or Care Of (opifonal) Mailing Address PHONE CITY STATE ZIP ACCOUNTADDRESS for fees and charges OWNER FACILITY/BUSINESS THIRD PARTY BILLING BILLING AND COMPLIANCE ACKNOWLEDGMENT: I,the un ' ant,certify that I am the Owner,Operator,or Authorized Agent of this Business,and I acknowledge that all PERMIT FEES, PENALTIES, ENFORCEMENT CHARGES and/or HOURLY CHARGES associated with this operation will be billed to me at the address identified above as the ACCOUNT 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 applicable SAN JOAQUIN COUNTY Ordinance 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 above facility/site address. I hereby authorize the release of any and all results and environmental assessment information to SAN .JOAQUIN COUNTY ENVIRONMENTAL HEALTH DIVISION as soon as it is available and at the same time it is provided to me or my representative. PLEASE PRINT APPLICANT NAME , 5HAZI& 14H'M 4 SIGNATURE TITLEDRIVER'S LICENSE# �L d wltlfylQ e :,aging IYt oaessttg Gomptete 8y €data f'