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c SQ" Joaquin:;County. tic.Health Services > nvironmt Health_Division DATE MASTER FILE RECORD INFORMATION FORM (EH 00151REvtseD 06Nt197y tZ�E/b fOA,.. D U4EOM�Y UNIT I V SM�DE .arvNISR ID# . CASA# L` � � ER FILE COMPLf=T tFfE LEVI G USINESS OWNER INFORMAT/ON: CNECFC/F OWNER CuRRENTLYonrF/cEwiTHEHD ........ ........ ........ .................. � y—,I}1��'��' �.{t .... ...........................}.--•--•---.---1........... �t PHONE BUSINESS OWNER NAME — — t "'IL�LsL`7,/v1v'��ry� _ 5�6. Q.. ZQ.I ................ l" .� Bus INES9NA FF, 1 �If t e t OWNER HOME ADDRESS 30,5- DRIVER'S LICENSE 'City Z, ///�� ��✓ STATE CA: 21P 6( 5—C.+7D 2 OWNER MAILING ADDRESS (ifD/FFERENTfrom Owner Address) Attention:or Care of (optional) -J Mailing Address City State Zip CORPORATION❑ INDIVIDUAL❑ PARTNERSHIP❑ LOCAL AGENCY❑ COUNTY AGENCY❑ STATE AGENCY❑ FEoAGENCYK OTHER❑ FACILITY FILE FAC1t ifY ED# CR03s Eis EI7# ACcouttr 10# t COMPLETETHEFOLLOW/NG BUSINESS I FACILITY I SITE INFORMATION: Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DIVISION 7 YES ❑ NO Is this an EXISTING Business LOCATION but a NEW TYPE of reeggu ted Business � e--++sss 7 YES NO C3BUSINESS/FACILITYlSITE NAME /\V o1,4N-f Me, �AW 4V L)1 "I o� �t ftC—WT 1_f�_CoC-11C_Torl SITE ADDRESS �� ` r , ` (\v G►--�v SUITE# USINE S PHONE q 44, CITY STAT zi 2a Mailing Address if DIFFERENT from Facility Address Attention:or Care Of(optional) Mailing Address City STATE ZIP SIC.CQDE APN# COMMENT_:::. .. THIRD PARTY BILLING INFORMATION: Complete if Billing Party is different from Business Owner Identified above. ............................ ............................................................................................................................................................................................................................................................................ BUSINESS NAME Attention:or Care Of (optional) Mailing Address PHONE CITY STATE ZIP ACCOUNTADDRESS for fees and charges OWNER FACILITY/BUSINESS THIRD PARTY BILLING Bn.t,lvc aver<ontrLlAvice:\CKNOw9,F.DGHF:N T: 1,the undersigned Applicant,certify that I am the ON7ter.Operator,or Authorized Agent of this Business.and 1 acknowledge that all PrR.111T FEES, PF.,v1LI s• E.VFORCF FVT CIbIRGEs and/or//OURLY CHARGES associated with this operation will be billed to me at the address identified above as the AccouNT Annllr.e.c for this site. I also certify that all information provided on this application is true and correct: and that all regulated activities will he performed in accordance with all applicable S,kN.IOAOt'rN CnINT)'Ordinance Codes and/or Slandards and STATE and/or FFDFRAL Laws and Regulations. As the undersigned owner,operator,or agent of the property located at the shove facility/site address. I herebv authorize the release of any and all results and environmental assessment information to S N JOAQUIN COUNTY ENVIRONNIE'NTAL HEAL"ill DIVISION as soon as it is available and at the same time it is provided to me or my representative. PLEASE PRINT APPLICANT NAME J1 IN G. VIMM� SIGNATURE DRIVER'S LICE SE# / TITLE OMM ]N QlN�" 1DHOTornpy gFritnRt'n) r� A Approved By Date Accounting Office Processing Completed H bate` f ' b 11