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�► 0 7555 I . ,., ,..: ..,. r..-n.,.�y.. r "."iT.:t�lisn�x „glncx ""�.!'fw"•M»�.v ...�w,.'s^�'�.4C""q"+'µ"y�• �a oa ulr orJn . ealt;' e tce EnvlronmenfaF �attf DIVISIorr,; � �s ti DATE s RW FORM (EH 00 1 S(REvIsED 072M7) ' MASTER FILE RECORD INFORMATION SHADED AREAO FOR EHD VSE ONLY C` �. ''+ ASF,. UNIT IV I ff OWNER FILE COMPLETE THEFOLLowING BUSINESS OW ER INFORMATION.' CHEcxiF OWNER CuRREnazroNF1LEw1rHEHD ................................................................._........................_......__................._ .............B......__................................. BUSINESS ...._.......:...PHONE..........�........................................................ OWNER NAME T�-�,M_______—_----—___—_IL !�_'_/ �__--__' n ^ ) ' _................................................................Flat................._..--•--..__.....M/......._..................................... ax....................................... L 1 BUSINESS NAME(If different from Owner Name) / 1 U✓1�1 i� /I U / � Sol-SEC/TAx ID# y } }� ( ry i OWNER HOME ADDRESS }-`7 } eS+ City � �� t) DRIVER'S LICENSE# i JC y(J Ill > fL ri( STATE C/ ZIP is OWNER MAILING ADDRESS (if DIFFERENT from Owner Address) Attention: orCare of (optional) Mailing Address City State ? Zip CORPORATION❑ INDIVIDUAL❑ PARTNERSHIP❑ LOCAL AGENCY❑ COUNTY AGENCY❑ STATE AGENCY❑ FED AGENCY❑ OTHER❑ It e FACILITY FILE '"`Factt Tri 104 R ,CRoss'Rs i ME K, ` f AccouNrlD - ia�' h, y� NIA COMPLETETHEFOLLOW/NG BUSINESS/ FACILITY/SITE INFORMATJON: Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DIVISION YES ❑ NO ❑ Is this an ExIsnNG Business LocAnON but a NEW TYPE of regulated Business 7 YES ❑ No ❑ BUSINESS/FACILITY/SITE NAME - l� SITE ADDRESS p SUITE# BUSINESS PHONE 400) CITY STA � E ZIP G(CrII�. 'e ATIQNI'"F'' -` j,w 'r �Yw°:. 3.'�-/{�.'3Ki,�S.s,;:"�`,v�.��:'', rt dna 7ML Mailing Address if DIFFERENT from Facility A ddress ; Attention: or Care Of(option/) a Mailing Address City STATE E Zip THIRD PARTY BILLING INFORMATION: Complete if Billing Party is different from Business Owner Identified above. .. ..................................................................�........... .............................................................. BUSINEss NAME o I I ? Attention: or Care Of (option/) A�UGt✓�G�Cit �t;OG"ny1,^�✓I M�✓I l�cc / Mailing Address �lvt/ , /V' 'S �)�� ,/ ` PHONE ( Y n CITY 5+0d< 1 Z/ ^ STATE c/-� ZIP 9 ACCouNTADDRZSS for fees and charges OWNER FACILITY/BUSINESS THIRD PARTY BILLING BILLING AND COMPLIANCE ACKNOWLEDGMENT- L the undersigned Applicant,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 tome at the address identified above as the ACCOUNTADDRESS for this site. 121S0 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 JOAQULN 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 `- 1 i APPLICANT NAME r(G I l l�?Qr1 SIGNATURE ;' �j TITLE DRIVER'S LICENSE# 1 Gl 1 CCS _ IPHOTQCQPY RFOU1RFnl owed B pate Accou�Hung Offtce Prod Pi` 4'' Date.. .. -� •� APPr Y'� .•.��:� �: ess Com ►e ed By'..;M.. '� r� � ..-s`. �.��,;