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Sam .b .. a oa a CQ .......... � FORM (EH 0015(REvtsEo 06N 1 i97) DATE Z/ MASTER FILE RECORD INFORMATION UNIT IV .......... ......... .. .. . . OWNER FILE COMPLETE THEFOLLOWING BUSINESS OWNER INFORMATION. CHEcKIF OWNER CURRENrtrONF1LEwiTHEHD ------------------------------------------------------------------- --------------------------------------------------------------.....................................-...............................................................------------------------------------------------------------------ BUSINESS P ---- ----------------- - — !— --_ S HONE OWNER NAME � ------------------------ •.rust MI Last ..................................................... .........`... ...................................................................................................... BUSINESS NAME(If different from Owne of c� a�n�al n �17r� SOC SEC/TAX ID# OWNER HOME ADDRESS I/,^ DRIVER'S LICENSE# C.tty s Lf Cr'a m en 7�'o v STATE CA ZIP /.- 7/sY OWNER MAILING ADDRESS (ifDIFFERENT,1rom Owner Address) Attention:or Care of option/) L?unalt,-) Mailing Address City State Zip CORPORATION, ORPORATION INDIVIDUAL❑ PARTNERSHIP❑ LOCAL AGENCY❑ COUNTY AGENCY❑ STATE AGENCY❑ FED AGENCY❑ OTHER Cl FACILITY FILE Face iTx.:>>l�# t l! tOB iiEP F# # �tctr 404.; t COMPLETE THE FOLLOWING BUSINESS / FACILITY / SITE INFORMATION: Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DIVISION Is this an EXISTING Business LOCATION but NEW TYPE of regulated Business?_ l /14"C sof O BUSINESS/FACILITY/SITE NAME SITE ADDRESS I- �� SUITE# BUSINESS PHONE hi /f/ CITY sTnIE� zip i use�n nFmruvr4o�c tie?x TtntF Mailing Address if DIFFERENT from Facility Address Attention:or Care Of(optional) Mailing Address City STATE zip :::.:.. iEw^ ;::::::. . ..... F'SIO Com^ ......::.......,>s:;... THIRD PARTY BILLING INFORMATION: Complete if Billing Party is different from Business Owner Identified above. ....... - ..........................................................•--•.---.-.---- --..................................................................................................r ........................................................................................................... BUSINESS NAME Attention:orCare Of (optional) /�a�ry �cvf�cLJrlfcc�/ Pct�r !/. Ru-f'fah Mailing Address2/Vv Sea�On /v� PHONE(fle'j'5 0,13 L� CITY /, r SGCLJ STATE ZIP AccQ([4LTf�DDRESS for fees and charges OWNER FACILITY/BUSINESS THIRD PARTY BILLING BILLI.NC AND COMPLIANCE ACKNOWLEDGNIE.VT: I,the undersigned Applicant,certify that I am the(honer,Operator,ot—Authori;ed.-Igent of this Business,and I acknowledge that all PER+ftT FEES, PENALTIEs, EPoPORCENtENT CHARGES and/or HOURLY CTARGES associated with this operation will be billed to me at the address identified above as the.Wr_OUM' : IDD RPSS 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 hereby authorize the release of any and all results and environmental assessment mf ation to SAV JOAQUIN COUNTY ENVMONMENTAL HEALTH DIVISION assclon as it is available and at the same time it is provided to me or my representative. PLEASE PRINT APPLICANT NAME 4� SIGNATURE DRIVER'S LICENSE# TITLE 6��j/� jj/ tJI1�!I/r7 1nHnrnrnPy RFQIIIRFn1 ApprovedILAocounting Office Processing Gormpteter Bate