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K� � 5 `* ^P �� Q�F;$ f.y: +b�1�Y ,,y}��e•, jywr�S•�r}ar �4e 5syd��-r++ <br /> r- - bKttN FORM <br /> DATE MASTER FILE RECORD IN 1� 1 <br /> t 4J� CASE# 1 <br /> .S . rocun,�nw. .OWNER ID# '[� UNIT IV <br /> OWNER FILE 2 '7 2r'06 <br /> COMPLETETHE FOLL0WING PROPERTY OWNER INFORMATION; CHEcxrF OWNER CuaREmzroNFtLEwrmEHD <br /> PROPERTY OWNER //-/� PERMMI!;ERVICE PNDN�'r/0) �0f -/0Jf fl/ <br /> NAME A(^J/�i r C�� �✓ �O/ f�(/ - 'vJ / <br /> First MI last <br /> BusINEsS NAME k/- SOC SEC/TAx ID# <br /> owner Home Address C ����J� D Ar <br /> DRrVER's LICENSE# <br /> _,777 <br /> City o- /��r GSC STATEZIP f�2 <br /> Owner Mailing Address <br /> Mailing Address City State Zip <br /> TYDF OF QWNFRRC-1u1D <br /> (^nO RAO eTinN 1._I iunnrtn��e� Deon+coc4llo I_1 FFn Af FNIY 1_I nT41FO I I <br /> F&r-ILI= VII <br /> . RossREFID# INV#FACILITY ID# <br /> MP E LL N F RMA <br /> Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ No ❑ <br /> Is this an EXISTING Business LOCATION but a NEW TYPE of regulated Busine/s�s�? YES ❑ No ❑ <br /> Bu&i%ESStrmLEFv4SnE NAME <br /> SITE ADDRESS SUITE# BusINEss PHONE <br /> CITY LJ� STATE ZIP <br /> II.BOARD OF SUPERVISOR DISTRICT ! ..,., LOCATION CODE KEYl I - +,at>.nwe-;J• 2.. I - - II <br /> Mailing Address if DIFFERENT from Facility Address Attention:or Care Of(optional) <br /> Mailing Address City STATE ZIP <br /> sicc'oDE`: '.L °- ` �1 APH -25 -t5 h` : <br /> THIRD PARTY BILLING INFO: Completeif Billing Party is different from Property Owner or Facility Operator identified above. <br /> BUSINESS NAME ./ - Attention:or Care Of (optional) <br /> /Cl—J'C•p <br /> Mailing Address PHONE X ��y <br /> /79 '0 �1v9 ��E Y�ao <br /> CITY STATE ZIP I'_lp 7 <br /> drr'n//Ate ADDREsC for fees and charges OWNER FACILITY/BUSINESS THIRD PARTY BILLING <br /> Ru i iHt arvn f nntrt t vNre A0 <br /> ti1 I'LLncntcv1: 1,the undersigned Applicant,certify that 1 am the Owner,Operator,or Authori ed.4gent of this Business,and 1 acknowledge that all PER,tf/T FEES, <br /> PENALT/ES,CNEORCEntErvTC//ARCEs and/or HOURLr CHARGES associated with this operation will be billed to me at the address identified above as the ArrorrvTAnna/-.cc for this site. 1 also certify that all <br /> information provided on this application is true and correct; and that 211 regulated activities will be performed in accordance with all applicable SAN JO.AQUINi 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,1 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 /> PLEASE PRINT <br /> NAME SIGNATURE <br /> ENT'AL�NFID <br /> R'S LICESE <br /> TITLE O DRIVOPY REOUIRED)# <br /> Approved By Date` NEMENNEW, <br /> 11, untmg Office Processing Completed By Date_. <br />