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01'i02/2002 11: 09 20946834; FIFTH FLOOR PAGE 04
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<br /> FORM {EH OO t SIaF.Iseo tT6n tt9T}
<br /> DATE MASTER FILE RECORD INFORMATION
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<br /> UNIT ix�'.}4$ •«• 5«"3ix'.°�lr »fix i:',?: `�'' UNIT IV
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<br /> OWNER FILE
<br /> :OMFLETETHE FOLLOWING BUSINESS OWNER INFORMATION: _CMFcKtF OWNER Cuaa�vrtronrFltEwrrrrEHO
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<br /> OWNER NAME --___--�__. —y--- __---___-----__—
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<br /> BUsINE9S NAME(If d/tlerernf from Owner Nama) / SOC SEe!Tax ID 0
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<br /> OWNER HOME ADDRESS
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<br /> OWNER MAILING ADDRESS (!f O/FFERENTfrom owner Address) i Attention: or Cara of (optional)
<br /> Mailing Address City State Zip
<br /> Fly AGENCY 13 OTHER 13CORPORATION Q INDIVIDUAL❑ PARTNERSHIP C1LOCALAr.& Q COUNTY AGENCY❑ STATE AGENCY❑
<br /> e•,:R«s' 4:<;::`JV�N....f�:. Lp:EP�i'l�:3��t�.`2.' FACILITY
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<br /> COII'fPLETETHE POLL OWING BUSINESS 1 FACILITY I SITE INFORMATION.
<br /> Is this a NEw Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DIVISION 7 YES ❑
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<br /> la thi s an EXISTING Business LOCATION buts NEW TYP£of regulated Business 7 1`Es fir' ND ❑
<br /> BUSINessIFACIUTY/SITE NAME / l J I
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<br /> ' SUITE? i BUSINESSPHON19
<br /> SITE ADDRESS
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<br /> CITY STATE 21P
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<br /> Mailing Address X01FFERENTf om Facilrly Aedrass I Atiendo or Care t?f(opli )
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<br /> Mailing Address City �^�1 >�A::i I:ti$.:°:.e•�>.:rax:'kE:;Z>:..'n'..,..:!'�ifi...>,. x
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<br /> THIRD PARTY BILLING INFORMA-now Complete if Billing Party is differentfrom Business Owner Identified above,
<br /> BUSINESS NAME ' Attentia orcare Of ( LOrIa!)
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<br /> Mailing Address PHONE /
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<br /> nos Qs for fees and charges OWNER FACILnY/BUSINESS THIRD PARTY SIUING
<br /> me.+ledge that all
<br /> Rtt LI`jCi1l'T COMPLI.V'ICR Ar
<br /> 0OWLEDGME`ST: 1,the undersigned Applicant,certify that I am the Oh"dr>pperaror,or Aurkorked Agew of this Businese,and l acl
<br /> PEIWIT FEss, PENAL71$S, ENFORCEVZNf CHARM and/or ffoizmi,C/LiR=associated with this operation will be billed to me at the address identified above as the_aLi0tlyr
<br /> ADDRESS for this site. I also certify that all information provided on this application is true and correct; and that all regulated asivities will he performed in accordance with all
<br /> applicable SANjOAQUtir CotNTT Ordinance Codes and/or Standards and STATE and/or FEDERAL Laws and Regulations. is the undersigned owner.operator•or agent of the property
<br /> located at the above facility/site address. I hereby authorize the release or any and all results and environmental assessment information to SAN JOAQUIN COUNTY
<br /> E,YVQ ONMt ENTAL HF,%.LTH DIVISION as soon as it is available and at the same time it is provided tome or my representative.
<br /> PLEASE PRINT
<br /> APPLICANT NAMESIGNATURE
<br /> �r� �"Ib -��L�EWI/S __ � it /.l ♦� y
<br /> DRIVER'S LICENSES
<br /> TITLE
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