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r« .. µ <br /> S2II.�QB f T L:411113 £i �tC �Es4 � kti3G2S tkfllCOf{T FORM iEHDoIs!aenaRoaa11ro7) <br /> DATE MASTER FILE RECORD INFORMATION <br /> - � UNIT IV <br /> OWNER FILE <br /> OHECKIF OWNER CuaRENYtYONFrLE wrTR EHO <br /> COMPLETE THEFOLLOWlNGBUSINESSOWNER INFORMATION-- __. —•••--•—•••------••- -- <br /> ..........__..............—..... -_..._._.__._.___.....__..__.._._I...__.____-•._.--_. PHONE <br /> BUSINESS i <br /> • <br /> Ra <br /> 1! -----• <br /> —_—_— <br /> —__L_____-- <br /> O"ER NAME <br /> ._......._—_.........._ <br /> SOCSECITAXIOt <br /> BUSINESS NAME(rf dfiarant lrctn OWrter Nerms) <br /> $ DRIVFN'a LICEtaEi <br /> j OWNER HOME ADDRESS <br /> STATE ZIP <br /> CRY <br /> Attention:orCare at (000418) <br /> OWNERMAILINGADORESS (ifD/FFERENTfro OwYaerAddresa) <br /> ! <br /> i State i Tap <br /> Mailing Address City <br /> CORPORATION INDIVIDUAL0 PARTNERSHIP LOCAL AGENCY C3 COUNTYAGENCY❑ STATE AGENCY 13 FED AGENCY El OTHER❑ <br /> FACILITY FILE <br /> FACRaTyiff tF.> <br /> COMPLETETHEFOLLOW/NG BUSINESS I FACILITY I SITE INFORMATION: Yi� cl No ❑ <br /> Ie this a NEW Buslne :%LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DIVISION? <br /> YES ❑ No 13Is the an OUSTING Buaineas LOCATION but a NEW TYPE of regulated Business;7 <br /> BUSINESSIFACILrrY/SITE NAME <br /> SUITE# BUSINESS PHONE <br /> SITE ADDRESS <br /> STATE LP <br /> CITY <br /> . .. ...._. Attention:Or Care Of(optional) <br /> Mailing Address AD/FFERENTIrvm Facility Address <br /> STATE LP <br /> Mailing Address City <br /> 5/f CDt7E <br /> THIRD PARTY BILLING INFORMATION Complete if Bllling g.Party is different from Business Owner Identified above. <br /> ....—_. Attention:orCare Of (OpdpW) <br /> BUSINESS NAME <br /> PHONE <br /> Mailing Addreas <br /> STATE LP <br /> CITY <br /> A=CUNTADORECS for fees and charges OWNER <br /> FACIIlTYIBUSMESS THIRD PARTY BILLING <br /> BILLING ANDCOMPLIANCE 4cK OV EDGMLTvr: I,the undersigned Applican4 cerdfy that I am the Owner,Operator,or Aaahorized Agent of this Business,and I aclarowledge that all <br /> pgJt}RT FEes. PEN.tGTfFs• ENF'ORn°V/'I'n'C1f�tSuzS and/or HOURLY CA GE associated with this operation will he billed to me at the address identified above u the ACCOUNT <br /> .PrAyirs for this site. I - E certify that all information Provided on this application u true and eu r and that all regulated activities will be performed in accordance with all <br /> nt information ttoons As the undersigned mater,operator, <br /> applicable SAN JOAQUIN Cot Ordinance Codes and/or Standards and STATE and/or FEDERAL Laws and Regulati <br /> loca[ed at the above facility/site address, I hereby authorize the release of any and all results and environmental assessmeo SSAN JOAQUIN COUNTY <br /> Aor agent of the property <br /> ENVIRONMENTAL HEALTH DIVISION as soon as it is available and at the same time it is provided to me or my reptvxntative. <br /> PLEASE PRINT <br /> SIGNATURE <br /> APPLICANT NAME <br /> DRIVER'S LICENSE Y <br /> TITLE <br /> APprttvad$Ir sOate: .. <br /> ADaaurtHts9 tlfRda ProcesstsgCompteted 8y flafa <br />