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07/28/99 08: 10 FAX 209 465 0631 FORWARD INC. Q002/002
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<br /> BATE MASTER FILE RECORD INFORMATION
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<br /> OWNER FIL tvUw�`ol�3(v/9
<br /> COMPL,PTETHEFoluowliva BUSINESS OBER ArFoRNAT/os- ✓ �J ,JC>♦E tt0 OWNER CuRmArTlrosr"w-rmeHi
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<br /> BUSINESS NAME Or Qf0brtent frwn Owner Name) SOC SEC/TAX 10>A
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<br /> OWNER HOME ADDRESS / 1 1!'i!• l_.I'1 y (j(, RRtVrzR'
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<br /> ( S k STATE ZIP 9sao 6
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<br /> OWNER MAILING ADDRESS (ifDIFFERF_1ilTtrnm pwnerAddnsea)
<br /> Attention:a•Care of (cPftov=ij i
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<br /> Mailing Address City Stata ! 21P i
<br /> oAPORATION INDIVIDUAL❑ PARTNER3KP CO LOCAL AGENcT O CoUNTf A=mcy Q STATE AGENCY❑ Fra AGENCT 0 OTH ❑
<br /> _ ROOF FACILITY FILE
<br /> COMPCy�ETH�FOLLOWING BUSINESS I FACILITY/SITE /NFORMAT/ON:
<br /> IS this a NEW fluaine"LOCATION net prevleusly regulated by the ENVIRONMENTAL HEALTH D1visiom T YEs ❑ No ❑
<br /> Is this an EXIST'ING Business LOCATTON buta NEwTrPs of nVulsted Busineetr? YES ❑ No O
<br /> BUSINESsII'AGILITI'/SITE NAME Cam pa n�
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<br /> S1T1:ADDRESS t
<br /> SUITE M 3 8USWOR PHONE .
<br /> - MIDI Sough LlwcoLW C�ve.hu�e i
<br /> CITY STnck-t-Ioo) 71,6 ZP Tian
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<br /> Mailing Address itD/FFERENT
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<br /> Mailing Address City /
<br /> StOL(< n t STA t zip 9So�r�G
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<br /> THIRD PARTY 13ILLING INFORMATION: Complete if Billing Party is different from Business Owner identiried above. a
<br /> BUSiNEss NAME' _. � ��I/► ',--- —-- 1/!U `I� i = Attention:arCare Of (4opt4vnq-------
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<br /> ACaQUAtrADaR§a for fees and charges OWNER FACII-rry(SUSINEss THIRD PARTY BILIJNG
<br /> 3}LLL�'C ti�T CO�tPtLAyt ��lUOWzt nCMeyT 1.the undersigned.tlppikant,ccrtiF, tbat I an the 04"c,Operaror,or.wAaricedAgert ofihIs Busincaa,artd I ackno.rlcdge that 4
<br /> -SAWr FEES, PE_NAL7TP3, E.%TORCGi ZW C94AG-S And/or HOURLP CHAROT-T assodared With this operation will be biped to me at the address identined above As the_Iecottntr
<br /> IDDR£SS for this uta. I Jxo certiW that all information protdded on this application is Irve and correct: and that all re.-ulated aelMOvs will be performed is accordancel,.ith Ali
<br /> ppricable SAtr JOAQUIN CO"TY Ordinancz Coda andJor Standards and STATE and/or FEDERAL Liz and ReSulationL As the undersigned o.mer,operator,or agent or the property
<br /> Dcated at the above facility/site addtesa, I hereby sutliorize the release of any and all result.& and envirnnmmlal assessment information to SAN JOAQUIH UI'T
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<br /> -.JWTJ tONMENTAL HEALTH DMS& as soon as it available and at the same time It u provided to me or my represcatati,'e,
<br /> PLEASE PRIM'
<br /> APPLICANT NAME /J v ' SIGNATURE
<br /> T1TLE / ORIVER'S LICENSESS
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