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S Joaquin . punt ' ,tic Health,Sery ces Environmen Health Division <br /> FORM (EH 0015(Rew4Eo 06171197} <br /> DATE � MASTER FILE RECORD INFORMATION <br /> SHNPW-&R Q-U0E.Q 10 ©tNhl�R FIS...: CASA UNIT I V <br /> OWNER FILE <br /> COMPLETE THEFOLLOWING BUSINESS OWNER INFORMAT/ON: CHEcKIF OW.N E R CURRENTLYONFILEWl7"NEHO <br /> ........... <br /> .............. .................. ................................. <br /> ....... <br /> ................................. <br /> PHONE <br /> . . . .. <br /> I►�j' �y/ <br /> BUSINESS ' �l/�'^' y� �(�.��ry�1\ <br /> OWNER NAME <br /> ..../�k�':1K�1.1L�11JY �C11 <br /> .................... <br /> S.Prr ...... ..VAI Q... ...... .... <br /> Q.., Zo.t . ctrl J <br /> BUSINESS NAME(If different fromOwnefINa ) T SOC SEC/TAx ID# <br /> I <br /> OWNER HOME ADDRESS ^D� T- / �/� 1U ' DRIVER'S LICENSG# t ) / ^ p <br /> CityQfn!►�� Cts 61 7 �� ✓ STATE ZIP -ZD J F <br /> OWNER MAILING ADDRESS (if DIFFERENT from Owner Address) Attention: or Cara of (optional) <br /> Mailing Address City State Zip <br /> CORPORATION Cl INDIVIDUAL❑ PARTNERSHIP❑ LOCAL AGENCY❑ COUNTY AGENCY❑ STATE AGENCY❑ FED AGENCY OTHER❑ <br /> FACILITY FILE r <br /> FAciLrTY 1f]'$ CTi ii REr 1[04.. AceounT 10# Y <br /> COMPLETE THEFOLLOWING BUSINESS I FACILITY I SITE INFORMATION: <br /> Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DIVISION 7 YES ❑ NO <br /> Is this an EXISTING Business LOCATION but a NEW,)TYPE ofregulated Business 7 I 1 YES xNO ❑ <br /> BUSINESS/FACILITY/SITE NAME <br /> SITE ADDRESS �� r • �" G�"v SUITE# ��SINE S PHONE <br /> oe <br /> CSTAT <br /> CITY ZI <br /> o T eft . s CD3 20 <br /> BOARD 00 SUPE DaQ13 <br /> Mailing Address ifD/FFERENTfrom FacifityAddress Attention_or Care Of(optional) <br /> b <br /> STATE ZJP <br /> Mailing Address City <br /> , <br /> r <br /> Slr"r`.nrs>^ APN# COM: MENT' ' <br /> THIRD PARTY BILLING INFORMATION: Complete if Billing Party is different from Business Owner Identirfed above. <br /> ......................................................... .. ? <br /> BUSINESS NAME Attention: or Care Of (optional) <br /> t <br /> Mailing Address PHONE <br /> t' <br /> CITY I STATE ZIP <br /> g�O��I�QQQgE$$ for fees and charges OWNER FACILITY/BUSINESS THIRD PARTY BILLING <br /> BII,I.tN(,.:VVD CONIPLIANCE AcKNoNyi.F,DGMFNT: 1,the undersigned Applicant,certify that I am the(timer,Operator,or,l uNmrized Ageni of this Business,and I aclumwledge that all <br /> PFR.IIIT FF.FS, PFMILTIFS, E,vFORCF.SIF,VT CHARGES and/or HOURLY CHARGES associated with this operation will he billed to rue it the address identified above as the <br /> ,IDDRF,SS for this site. I also certifv that all information provided on this application is true and correct: and that all regulated activities will he performed in accordance with all <br /> applicable S.1N.JOAOt,t)4 COtrvTV Ordinance Codes and/or Standards and STATE and/or FFDFRAL Laws and Regulations. :Ls the undersigned owner,operator,or agent of the property <br /> located at the above facilitv/site address, 1 hereby authorize the release of any and all results and emironmental assessment information to S N JOAQUIN COUNTY <br /> ENVIRONMENTAL 10"A.LT11 DIVISION as soon as it is available and at the same time it is provided to me or my representative. <br /> PLEASE PRINT <br /> APPLICANT NAME ,JUIN G. `EMW SIGNATURE 2 <br /> A <br /> DRIVER'S LICE SE# <br /> TITLE 1im'ImCM IN CIM- (OUnTnrnpY grotjigrn) IN//\ e' <br /> P <br /> pC1ate I<: Actnfing(Niue Processing Completed By Date <br /> AprovedBY zou <br />