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Sa> JIa u COunty "Abiic Health Services En me- -I nt H altit Div s orl FORM (EHODIS(REVI3ED08111197) DATE MASTER FILE RECORD INFORMATION UNIT IV 9NAO60 neLeal2R END Vaa.Siet.I � �' � `� . 9V � �. OWNER FILE COMPLETE THE FOLLOWING BUSINESS OWNER INFORMATION: CHFCxrF OwNERCuaaEHrcroNFr�EwrrHEHD .......................:.......................................................................................... ...... .......... .................. BUSINESS PHONE OWNER NAME '-----------------y-------------------- ---� /�'/� � Q ...................F�11........................................Ml...................................._.........lftJt......_..--- .----- I s a — v � BU3INE33 NAME(If d^rr*rr(from Owner Name) : SOC SEC I TAX ID g R�1co Qror� )c'ts Cca�Q� �7 IGo ,!J OWNER HOME ADDRESS Ccw"- - n OoAc� t y\., DRIVER'S LICENSE g city �Pr Ver\M A Y STATE C Q LP 9 D OWNER MAIUNG ADDRESS (ifDIFFERENT fiDrn OsvrwAddr*") Attention-or Cara of (- I boats/) PAJ l //�J Mailing Address City State/ /1- 7�P 2 CORPORATION INOIVIOUAL❑ PARTNERSHIP❑ LOCAL AGENCY❑ COUNTY AGENCY❑ STATE AGENCY❑ FED AGENCY❑ OTHER❑ FACILITY FILE AaAll" COiMPLETETHEFOLLOWING BUSINESS / FACILITY /SITE INFORMATION: Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DIVISION 7 YES fl NO f Is this an EXISTING Business LOCATION but a NEW TYPE of regulated Business 7 YES ❑ No X BusiNESSIFACILITYISITE NAME (\ { r 0 "V�\�1vv- ^r n` ( SITE ADDRESS SURE M BUSINESS PHONE .\.� S`TI�T� LP CITY ��•� � J` - Mailing Address ODIFFERENrhvm FsedifyAddress Attention:or Care Of(optyorls ` P. Mailing Address City M O ✓n q STATE C LP SIC CaDL( RP#i 177777 ` TJ THIRD PARTY BILLING INFORMATION: Complete if Billing Party is different from Business Owner Identified above. ..............._..........................................................................................-.-......................... ------..._...........................,............................................................ --._........._...........................................-•- BUSINE33 NAME Attend n:or Care Of (opdorrall Mailing Address ; PHONE CITY STATE LP Ar�-OUNTAO _Ess for fees and chargesGINNER FACIL.IIY/BUW4ESS THIRD PARTY BILLING IILLLVC L'yD COMPLIANCE ACKNOWLEDGML`IT: I,the undersigned Applicant,certify that I am the Owner.Operator,or Authorized Agent oft"Business,and I acknowledge that all PERMIT FEES, %r.vA nEs, ENFORCEMENT CFLiRGES and/or f{OffRLr CHARGES associated with this operation will be billed to me at the address identified above as the ACCOtN. T ADDRESS for this site. I also certify that ail information provided on this application is true and cornet; and that all regulated activities will be performed in accordance with all 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 prnperry located at the above facility/site address.. I hereby authorize the release of any and all results and environmental assessment info ation to SAN JOAQUIN COUNTY ENVIRONMENTAL H ALTH DIVISION as soon as it Is available and at the same time it is provided to me or my representative. PLEASE PRINT i / APPLICANT NAME RE TITLE DRIVER'S LICENSE�HOTot`noy vcntnpcnl Atsproved Sy Date / �j ,Rcco1><etir►g.Oifiae[►stYlietislirtg loteed9rr iiatas ..