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;µ," Sac`" Jo "uriCoun r `Health enflce" nvrron e>~iia ' eatt. Dvisio FORM (EH0015(REv;sED0723t97) DATE. Z"7- MASTER FILE RECORD INFORMATION ` ' SNAOEO AREAE FON EMD V3E ONLY ' � UN I ■ IV , OWNER FILE COMPLETE THE FOLLOil— USINESSO NER INFORMATION.' CHECK/F OWNER CURRENTLYoNF/LEwTHEHD ........................................................................................._...._.......__.............._.............__...................................__..........._............................._.................._................................................. . BUSINESS 9 ! ? ? PHONE OWNER NAME i—•�J_--------------�— -------- ..................................................................fix..............................._.......Ml......._..............--_......................L...................._................. BuSINEss NAME(If different from Owner Name) ' SOC SEC/TAx ID# OWNER HOME ADDRESS DRIVER'S LICENSE# City STATE : ZIP OWNER MAILING ADDRESS (fDIFFERENTfrom Owner Address) Attention:orCare of (optional) Mailing Address CityP&> '2 1 Q / �-�J� /� E State /J� ' Zip TC :R3 CORPORATION INDIVIDUAL❑ PARTNERSHIP C3 LOCAL AGENCY❑ COUNTY AGENCY❑ STATE AGENCY❑ FED AGENCY❑ OTHER❑ FACILITY FILE .. *r'it:'?w'a•.: � ;-. '.d+`::+�.;�. •`�at-r-!z�k"' � au�# �'� - i�-v.-+. ;:5 'h at {r:s"'rR FAcIttTr9D - CRossREFI� � " £ AccarNtlD# a.�- �.3 N r-_ COMPLETETNEFOLLOW/NG BUSINESS / FACILITY/SITE INFORMATION: Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DIVISION? YES ❑ No lj� Is this an�EFxISTING�$Business LOCATION but a NEW TYPE of regulated Business(? /� YES p No [3/� Bus Dc[�l TYI IyE4 r`ME a (1 l ^(PA qp&!i c� LA SITE ADDRESS {/ . � '� j� SUITE# BUSINESS PHONE CITY ST A ZIP I \ r tjPFRviso _a .ai .yc, '�..Y- Mailing if RENT o i Address Attention:or Care Of(optional) Mailing Address City S i ZIP ��dgGrx SIC CODE fi � p�� 3'APN ...F fia�._ *x. COitMErrr�`€ .. i. w ;s' p ".a �. THIRD PARTY BILLING INFORMATION: Complete if Billing Party is different from Business Owner Identified above. ....................................................................................•---....,..._.............,,W..........._-...-...-._-..._......--.....-...........-...-.-.--.... -........................................................,-, a "A- "�`IyMcEN1........................... BuslNEss NAME Attention: orCare Of (op tionaqCEIV E Mailing Address PHONE AUG — 1998 CITY STATE 3AT7POp,(tUIN COUNTY ACcouNTADDREss for fees and charges WNER FACILITY/BUSINESS THIRD PARTY BILLING BILLING AND COMPLIANCE ACKNOWLEDGMENT: I,the unde igD plicant,Certify that I am the Owner,Operator,or Authorized Agent of this Business,and I acknowledge that all PERMfT FEES,PENAL77Fs,ENFORCEME1vT CHARGES and/or HOURLY CHARGES associated with this operation will be billed to me at the address identified above as the ACCOUNT ADDREYS 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 I aws 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 any 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 TITLE DRIVER'S LICENSE# (pHnj=crY RFnt nRFn) Da Oftt&C Pro m