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A <br /> ................ <br /> DATE q MASTER FILE RECORD INFORMATION <br /> FORM [EH0015(Rr=visED0611119T) <br /> ................x ....... <br /> ............... ....... <br /> .......... <br /> ................... <br /> qHADED AF46 F Foot EH une�m . ....... ...................... <br /> . ...... .. <br /> UNIT IV <br /> OWNER FILE L& *' 0.�-tPl <br /> COMPLETE THEFOLLOWING BUSINESS OWNER INFORMATION: CHECKIF OWNER CuqREArrLr ON FILE WTH EH D <br /> ......................................................................................................................................................................................................................................................................................................... <br /> PHONE <br /> BUSINESS <br /> ran+k ly)'f C C.14 <br /> - '-?NoaA frac L_j%C)e-*la+'e-S - :: 6t15 - JAl(o5- 7-300 <br /> OWNER NAME -------- t�L .---.... <br /> ....................................................................aq(....................................... ...............................................Last.................................. <br /> BUSINESS NAME(if different from Owner Name) SOC SEC TAx ID <br /> OWNER HOME ADDRESS DRIVER'S UCENSE <br /> CIO 6ow(ers (NA� 1.505c) IAC)R�aecL 8\Y61. , S+e <br /> city STATE <br /> (f zjp q5 H <br /> OWNER MAILING ADDRESS (ifDIFFERENT!rom Owner Address) Attention:or Care of (optional) <br /> Mailing Address City State zip <br /> Typr nr(0) <br /> CORPORATION 0 INDIVIDUAL❑ PARTNERSHIP 0 LOCAL AGENCY❑ COUNTY AGENCY 0 STATE AGENCY C3 FED AGENCY C1 OTHER❑ <br /> FACILITY FILE <br /> ......... .. ... <br /> ....... .... <br /> ............ ............. <br /> . ......... <br /> C <br /> COMPLETE THEFOLLOWING BUSINESS / FACILITY/SITE INFORMATION: <br /> Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DIVISION? YES ❑ No 11 <br /> Isthis an EXISTING Business LOCATION buta NEW TYPE of regulated Business 7 YES 0 No 11 <br /> BUSINESS/FACILITY/SITE NAME <br /> NW corner op W-(rran4- ,%c- 90CLot 6.q& Maglcc (A <br /> NJ <br /> SITE ADDRESS l t SUITE# BUSINESS PHONE <br /> CITY STATE i zip <br /> 'bra c cpr <br /> ........... ....... <br /> ............ .... ... ............... ............. .... <br /> .. ... .... . <br /> .. ......... .......... <br /> Mailing Address ifOIFFERENTfi-om Facility Address Attention:or Care Of(optional) <br /> Mailing Address City STATE ZIP <br /> . .............................. ......... .. .......................................... ......... <br /> ............ - --il............... .............. . ... .......... ................... <br /> ...... ............. .................... <br /> .... ...... ........ ...... ........ .... .......... <br /> ............. ... ....................... <br /> ....... ......... ..... ........o..... <br /> ................ <br /> ..... ..... ......................... <br /> ..... .............. <br /> .... .............. <br /> . .......... ----- <br /> ........ . . ........ <br /> ............. ---- -- <br /> . ......... . ..... . .......... ......... <br /> X.: . ........ ... . ... ... .... <br /> ... . ...... ............. . ...... .............. <br /> .... ............. <br /> ........ ----- <br /> ................... <br /> ................ <br /> -IQ . . .... . ... .... .. ......... X.X. ..... ...a------- <br /> rx..aE ..luoilim, . .. . ... ..... ...... <br /> APK... .. . . ......... <br /> THIRD PARTY BILLING INFORMATION: Complete if Billing Party is different from Business Owner Identified above. <br /> ........................................................................................................................................................................................................................................................................................................ <br /> BUSINESS NAME Attention:or Care Of (op nal) <br /> La+ 10-w\ O-AA L4) X�nt gloklrr <br /> Mailing AddressPHONE <br /> (65o --rown <br /> CITY <br /> C—[46- Ales&- STATE(f ZIP q I(e 2,41 <br /> for fees and charges OWNER FAciuTy/BusiNEss <jHIRD�PARTY BILLING <br /> Bti.t,rN*G;l�NDCOMPLIANCE ACI,LNOWLEDCNIENT: 1,the undersigned Applicant,certify that I am the Owner,Operator,or Authorized Agent of this Business,and I acknowledge that all <br /> PExifir FEES, PENAL77ES, ENFORCEMENT OuRGES and/or MOURLY 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 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 <br /> 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 <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 /> APPLICANT NAME Tin(Ver 14airr SIGNATURE <br /> DRIVER'S LIC SE# <br /> TITLE A �D <br /> .............. <br /> ....... w CBS nai .......... <br /> ........... . <br /> - oproye- .......... <br /> A ........ <br />