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�°'r.°�- v�^5...°blt"" Y� n�"}"x'"� �'.-e+' ;sw� x+Sa`.p.1r.:w�.......- -T'�"S'�"a: � r ✓r.+...: San ,Ioa uirrGotJnt ttlfiealtr'SeIcEnvironmer HeatDiylsiorrf FORM (EH 00 I S(REVISED 07/23197) I5ATE '�./ ' MASTER FILE RECORD INFORMATION I ' SHADED AREAS FOR EHD VSE ONLY , � {./NIT I V OwNEtrID ASS, 1 > OWNER FILE COMPLETETHEFOLLOW/NG BUSINESS OWNER INFORMAT/ON: CHECKIF OWNER CURREAraYONFILEwiTHEHD BUSINESS i / i PHONFj' ( / OWNER NAME "-- ——————— ————------ u, ...................................................................fiat..........................;...._.......M......._...........___.._......_....»....Anit...................__.................� BUSINESS NAME(tf different from Owner Name) //� ( SOC SEC I TAx ID# OWNER HOME ADDRESS DRIVER'S LICENSE# i City �t�L{ 1�_ �L l / STATE ZIP OWNER MAILING ADDRESS (if DIFFERENT from Owner Address) Attention: orCare of ( tiionl) Mailing Address City ? I, State i Zip CORPORATION❑ INDIVIDUA PARTNERSHIP❑ LOCAL AGENCY❑ COUNTY AGENCY❑ STA ENCY❑ FED AGENCY❑ OTHER❑ FACILITY FILE Fnciu�TrlD J ., h g CRoss R D A co res , 1. "04 N COMPLETETHEFOLLOW/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 LocAnON but a NEW TYPE of regulated Business 7 YES ❑ No ❑ BUSINESSIFACILITYISITENAME j CtL, �� /� 1 ' SITE ADDRESS J 1 v ESUITE# E BUSINESS\PHHOONE CITY �l ('/^�( • STAFE ZIP ,7 KFYJ Mailing Address if DIFFERENT from Facility Address Attention: or Care Of(optional) Mailing Address City STATE E Zip yrs?"S.'"., SIGCoDe .. +APN: �r' s �� x�i "COMMENT Y4 a�z'1 .tzh yf1 «3i A THIRD PARTY BILLING INFORMATION: Complete if Billing Party is different from Business Owner ident>fed above. '.--...-"--'.............................................................. _ __. .......................................'-•--......._........................._................................ ................................ ...._.............................................................._.... BUSINESS NAME l/ Attention: or Care Of (optional Mailing Address S4e,74 G� J -SfE r PHONE �!/✓^ _ CITY .S STAT-/-)4 ZIP AcccouNTADDREss for fees and charges OWNER FACILITY/BUSINESS THIRD PARTY BILLING BrLLING AND COMPLIANCE ACIGNOWLEDGMENT: I,the undersigned Applicaut,certify that I am the Owner,Operator,orAuthomed Agent of this Business,and I acknowledge that all PERMIT FEES,PENALTiFs,ENFORCEAfFATCHARGEs and/or HOURLYCH ARGES associated with this operation will be billed tome at the address identified above as the ACCouATADDRES.S 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 CouNTv 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 ;��1/� ;� f(� 7 J�J�J� SIGNATURE TITLE /j n. DRIVER'S LICENSE# / '�✓ � �• (PHOTOCOPY RFOttIRFnI bApprOVBd Y-1 �` .=-ix=sib„ s. ...,.,,,...rv::esa•a�r-•�Ar.-_ -�e �, ,, ,,� ;AccountJng Office Processing Completed By ,_. ys _w