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Sam Joaquim,Cain <br /> FORM (EH OD 15(REvtsEo Dan 1 re T) <br /> DATE MASTER FILE RECORD INFORMATION <br /> ........... <br /> UNIT IV <br /> OWNER FILE <br /> COMPLETE THE FOLLOW/NGBUSINESSOWNER INFORMATION: CHECK IF OWN ERCuRREAvrtrONFILE*7THEH0 <br /> .............I......................................................---------...........................,_........................................................---......--...................................._................._..._................................................................ <br /> BUSINESS <br /> PHONE c� �/ d <br /> OWNER NATUL`yl----------- ---SEnwTif1 -----------? O7/T <br /> ———— <br /> ...F (. ........................ Mt ...... .............�d3.t...................... <br /> .. .. .. .. ..... ... ................. <br /> Ll <br /> NE3tS= di/lerwnf Iom Owner Name �/� ? Soc SEc/TAx 10 <br /> .s--- 33- 07ZSL-7 z. <br /> L /'I,F-- ti-,E:�(-re—f-0 <br /> OWNER HOME ADDRESS /Z S C. S:e .�S Z(o Z.,, DRIVER'S UCENSE9 <br /> CSty t�0„f /"ICJG CA jZ.L L STATES^ LP <br /> OWNER MAILING ADDRESS (itDIFFEREAfr&om OwnerAddrw=) Attention: or Care of (opborsal) <br /> SG/ lOtlS 5 T tra+�r S� / Hi ke. 14e elera <br /> Mailing Address City State C¢ Z'P <br /> CORPORATIO" INDIVIDUAL❑ PARTNERSHIP❑ LOCAL AGENCY❑ COUNTY AGENCY❑ STATE AGENCY❑ FED AGENCY❑ OTHER❑ <br /> FACILITY FILE <br /> ,.;;FAcsstTx i[1;1� :;.> ;: ,;i .::L:Ht�ss. ai�a1E-. ;.:: 1 p r>1CCitt1litF 1���":::'z.;: •: .. . <br /> COMPLETE THE FOLLOWING BUSINESS I FACILITY / SITE INFORMATION: <br /> Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DIVISION 7 YES ❑ No ❑ <br /> is this an EXISTING Business LOCATION but a NEW TYPE of regulated Business 7 YES ❑ NO ❑ <br /> BUSINESS/FACILITY/SITE NAME G�G.1 hC� /7GCo�-/�ce�✓�ee0/Ht.� / <br /> SITE ADDRESS pr�,a3!lt,� welet'-f el DievCd-0I , 1•l te.Y`_I SUITE BUSINESS PHONE <br /> CITY 5 / STATE/ LP <br /> Mailing Address i/O/FFERENT liom Facility Address Attention: or Care Of(gptiorsal) <br /> aw tot J� Sil �`ttk� <br /> Mailing Address City STAT <br /> Ee4 LP <br /> ::. <br /> SIfi:fiOt7E:: >iC ` r'::i::: :'>.:: <br /> T <br /> complete if Billing Party is different from Business Owner Identified above. <br /> ....-_-------------------------------........ _-.... <br /> BUSINESS NAME HT 1 V Attention:or Care Of (optional) <br /> Mailing Address 1 S } ,. ,/ �._ PHONE <br /> Cm 'S �;�. � STAT 6� /'1 LP GSI S >,62---� <br /> ACa9MAlTADDRESS for fees and charges OWNER FACIUTY/BUSINESS THIRD PARTY BLuNG <br /> BILLING NlD COMPI IANCE ACKNOWLEDG�ME.YT: 1,the undersigned Applicant,certify that I am the Owner,Operator,or.4athorued.4gent of this Business,and I acknowledge that all <br /> PERMIT FEES, PENALTIES, ENFORCEMENT CAARGES and/or HOURLY CHARGES associated with this operation will be billed to me at the address identified above as the Acroyvr <br /> ADDRESS for this site. I also certifv that all information provided on this application is true and correct, and that all regulated activities will be performed in accordance with all <br /> 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 <br /> IOCated at the above facility/site address, I hereby authorize the release of any and all results and environmental assessment information to SAN JOAQUIN COUNTY <br /> Er-VTRONMENTAL HEALTH DIVISION as soon as it is available and at the same time it is provided to me or my representative. <br /> PLEASE PRINT <br /> APPLICANT NAME �+t�.4c�Q_I�✓t��e SIGNATURE <br /> DRIVER'S LICENSE i (�r� <br /> TITLE �� �� �pHnrnrnavaFotuaFnl'w3I'��$ <br /> i Approved.l3y DaLs Aoaautttn9 Ofliaa :0011100 rgY .. r E3ate i <br />