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IT 1WAP 0 7i1 SICi, a��ll` 1iCS AEry1�l )�1177 �I,HaIII,dIVIS101lEEN FGV,M I� 3 <br /> DATE MASTER FILE RECORD INFORMATION "MFR" <br /> : -111-1 <br /> � =t��z�y� UNIT IV <br /> SHADED AREAD FOR EHD USE ONLYMa. ��j'j"'4}- +CAE M 1 ffi } <br /> }} <br /> __ OWNERFILE <br /> COMFLETFTHEFOLLOW/NG PROPERTY OWNER INFORMATION: CHEcKIF OWNER CURRENTLYONFILEWIrHEHD <br /> PROPERTY PHONE <br /> OWNER NAME <br /> FI-s( M, Q/] les( <br /> BUSINESS NAME I I J!'G✓" `r SOC SEC/TAX ID# n� <br /> Dnl-iN,ysO/y/ 1T —A <br /> Owner Home Address — DRIVERS LICENSE# �^ <br /> City STATE — ZIP <br /> Owner Meiling Address <br /> /a L91 <br /> Mailing Address City State 73)-20 Zip /3)-2b <br /> CORPORATION INDIVIDUAL❑ PARTNERSHIP❑ FED AGENCY❑ OTHER❑ <br /> FACILITY FILE <br /> L r+ Tl';-r3,4 SS KS+ t i. .i:. �1 ,� ACCOUNT IU x' • t <br /> COMPLETE THEFOLLOWING BUSINESS/FACILITY/ 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 of regulated Business 7 YES ❑ NO LLL~~~kkkfffddA/ <br /> BUSINESS/FACILITY/SITE NAME <br /> SITE ADDRESSL°+t, C I /7 ^, RITE# BUSINESS 0%E 9� ^ <br /> CITY t 15 V STATE,/4 <br /> Z/I"P /Ky(Q 4 _ <br /> ,� k s i "�Ifzk+t,.,.t« :IS"&i•,m, ,z.i <br /> FIgUPE I, r, o ff Od r tt rt 3 n s�Ey <br /> is - #2 ,d«,.....,.w. <br /> Mailing Address IfOIFFERENTfrom Facility Address - Attention: or Care Of(optional) <br /> A)- <br /> Mailing Address City CD". tJ STATE&;E ZIP <br /> CYIC� <br /> Ci iC1 O <br /> THIRD PARTY BILLING INFO: Complete if Billing Party is different from Property Owner or Facility Operator identified above. <br /> BUSINESS NAME Attention: or Care Of (optional) <br /> Malling Address PHONE <br /> CITY STATE ZIP <br /> AccouNrADDREss for fees and charges OWNER FACILITY/BUSINESS THIRD PARTY BILLING <br /> BILLING AND COMPLIANCE ACKNOWLEDGMENT: 1,the undersigned Applicant,cerlify that I am file(honer,Opernlnr,or Authorized Agew of this Business,and I ackrimiledge IIIA(all <br /> PEmfn-FEES,PENALTIES,ENFORCF.AIFivTCIURcrFv and/or IIOURLYCIIARGF_V associated With this operation Will be billed to me at the address Identified above ns the ACCOUNTADDRF_SS <br /> for this site. I also certify that all Information provided on(his application Is true and correct;and that all regulated activities Will he performed in Accordance avi(h All Applicable SAN <br /> JOAQUIN COUNTY Ordinance Codes and/or Standards and STATE and/or FFDF,RA1.Laws and Regulations. As(he undersigned owner,opers(or,or agent of the properly IocAled n(the <br /> above facility/site address, 1 hereby authorize the release of any and all results and environmental assessment Information to SAN JOAQUIN COUNTY ENVIRONMENTAL <br /> HEALTH DIVISION as soon as It is available and at the same time it Is provided to me or my representative. /1 r L-O o If-- <br /> PLEASE PRINT /' l•� <br /> APPLICANT NAME D U e� ��un f T-!� Sf oras a� ���'TD2/11 SIGNATURE <br /> Lj <br /> TITLED <br /> ���� � DI 1°� - DRIVER'S LICENSE# <br /> Pr ) -- <br /> � .. � � e ��ro, ��.<: t�<:; +,,:, ..�... 'ogle',, I ,,. • :� �t <br />