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X 7 3 :. :.::::::.:::::.::. .::.::::::::::::::::::::::::::::::::::::.:::::::::.:::.: : ..sr 1t1R110:6 : + 11 'l:# C# u ...: ::::::: ............ ::::::.::: ... . ................. ......... ......... . DATE MASTER FILE RECORD INFORMATION FORM {EH 0015(REvtsEo 08/11/97) SHADED AREAE FOR EHD U!E ONLY s/{ �.::. . ...::::: � �� ..:.:. :.::.::. .:: ; .:: . :. :. : UNIT IV OWNER FILE COMPLETE THE FOLLOWING BUSINESS OWNER INFORMATION.' CHECKtF OWNER CURRENTcr�-ErvitHEHD E] ................................... ................................................... .................. .. ........................: ................""".."..."..........................................""............. " ,7 BUSINESS �-------..z-----.;f- �LL nt t 5 ---V n� L- �'� '� PHONE l OWNER NAME ----=---= ---------------- �� J ................"................................""................Fisf............"..........................M(..............................................LAs.1"..................................... BUSINESS NAME(If different from Owner Name) SOC SEC/TAX ID# OWNER HOME ADDRESS S IL 0,v, e,/ J2L«c ,r. IL4 i DRIVER'S LICENSE# city c)rL /.. -l. �Z E STATE LP / 2- OWNER OWNER MAILING ADDRESS (ifD/FFERENTfrom Owner Address) Attention:or Care of (optional) Mailing Address City state ZIP CORPORATION❑ INDIVIDUAL PARTNERSHIP❑ LOCAL AGENCY❑ COUNTY AGENCY❑ STATE AGENCY❑ FED AGENCY❑ OTHER❑ FACILITY FILE ::.:: :.::::;::: ::::O�itx+Ill.iiF .##:#..:...::::..:................. ............. . ........ .. .... .. COMPLETETHEFOLLOW/NG BUSINESS / FACILITY/SITE INFORMATION: Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DIVISION? YES ❑ NO Is this an EXISTING Business LOCATION but a NEW TYPE Of regulated Business T YES ❑ NO BUSINESS/FACILITY/SITE NAME e y V 1 c �'+-V KG�•" SITE ADDRESS A SURE# BUSINESS PHONE CITY STATE Zip Mailing Address ifD/FFERENT&om Facility Address Attention:or Care Of(optional) Mailing Address City i STATE E LP THIRD PARTY BILLING INFORMATION: Complete if Billing Party is different from Business Owner Identified above. .............."............."""......"....................................."......................................................................................................................................"."..""""......."....................................................................., BUSINESS NAME Attention:or Care Of (ophbnal) Mailing Address i PHONE CITY STATE LP AccouNTAODREss for fees and charges OWNER FACILITY/BUSINESS THIRD PARTY BILLING BILLING AND COMPLIANCE ACKNOWLEDGMENT: I,the undersigned Applicant,certify that I am the Owner,Operator,or Authorized Agent of this Business,and I acknowledge that all PEWIT FEES, PENALTIES, ENFORCEMENT CHARGES and/or ffouRLY CHARGES associated with this operation will be billed to me at the address identified above as the ACCoU,NT ADDRESS 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 COUNTY 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 herebv authorize the release of anv 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 SIGNATURE DRIVER'S LICENSE# TITLE lPHOTOCOOV acoutarnl >=`;::• :::;:I_;:<;: A roved:'R >>:::.... O#five; racesslxl .:::.:::><:...................... -: :..;..;: