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DATE San Juin County Environmental Healt*partment <br /> j ( ;' "� <br /> MASTER FILE RECORD INFORMATION "MM" <br /> SHAnFn ARFAC Frig FHn 11gF nNI Y OWNER ID# /1�i 00 1 q f CASE# UNIT IV <br /> VO/tJWN/ER FILE <br /> COMPLETE THE FOLLOWING PROPERTY OWNER INFORMAI70N; CHECKIF OWNER CURRENTLYoNFrLEwrTH EHD <br /> PROPERTY OWNER NAME / -eV t /Jn C /� PHONE 0L(J C ' I/ <br /> First M1 / F r` lLast <br /> BUSINESS NAME SOC SEC/TAX ID# <br /> Owner Home Address (i / 6 w' / �,u f ` /4 V DRivER's LICENSE# <br /> city L„L,h !o G STATE ZIP 7S- J ? Q <br /> Owner Mailing Address S 1 ✓✓ <br /> Mailing Address City ✓ State Zip <br /> T'PF nr OwNFRCHT <br /> CORPORATION❑ INDIVIDUAL Q PARTNERSHIP❑ FED AGENCY❑ OTHER❑ <br /> FACILITY FILE <br /> FACILITY ID# CROSS REF ID# ACCOUNT ID# <br /> ' =RXO <br /> 7--to'J—INV# 11 <br /> COMPLETE THE FOLLOWING NF RMATI ND <br /> Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ No El <br /> Is this an EXISTING Business LOCATION but a NEW TYPE of regulated Business? YES ❑ No <br /> BUSINESS/FACIIITY/SnE NAME <br /> SITE ADDRESS SUITE# BUSINESS PHONE <br /> CITY STATE ZIP <br /> BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEY1 T <br /> KEY2 <br /> Mailing Address ifDIFFERENTfrom Facility Address Attention:or Care Of(optional) <br /> Mailing Address City STATE ZIP <br /> 1SIECO. <br /> APN# COMMENT: <br /> THIRD PARTY BILLING INFO: Complete if Billing Party is different from Property Owner or Facility Operator identified above. <br /> BUSINESS NAME Attention:orCare Of (optional) <br /> Mailing Address 7 O lN�j s7t e L' �ZS f PHONE O, Q�- 1' L{5-j- <br /> � C �t ��- U l <br /> Cm /11) <br /> 1, 4 "I h I; l/-G r w o V C[ STATE <br /> ZIP '7S-670 S67O <br /> A�r•niiAr-AapREw for fees and charges OWNER FACILITY/BUSINESS THIRD PARTY BILLING <br /> nn.LlNc AND CoMPI.IAN(,F AcKNowLFncytFNT: 1,the undersigned Applicant,certify that I am the Owner,Operator,or Authorized Agent of this Business,and I acknowledge that all 1'E1?31IT FE&4, <br /> PENALTIES,ENFoRcEmFNTCHARCEs and/or HOUR[YCHARGss associated with this operation will be billed to me at the address identified above as the A ''OA tom'for this site. I also certify that <br /> 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 <br /> 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 hereby authorize the release of <br /> any and all results and environmental assessment information to SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my representative. <br /> APPLICANT NAME ;C IC CC PLEASE PRINT SIGNATURE <br /> TITLED <br /> 't `C f i �r r Ll F �\ DRIVER'S LICENSE# 1 Cl t�` \ (PHOTOCOPY REQUIRED) l <br /> Approved By Date Accounting Office Processing completed By Zy� Date 7-7-t6 2, <br /> 29-02-002 April 25,2003 <br />