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an.ioai` akt Count ulaflc Hsal; SeruWas Envtrott tat Heath 131Yis3r n <br /> 7 <br /> DATE L 3 OZ- MASTER FILE RECORD INFORMATION <br /> FORM tEHDo+3giEYtsemoeHtre7f <br /> a..ern sarwe roaEHm o.r Dai. 7 <br /> S-- UNIT IV <br /> PP f` gg11f1�, f <br /> COMPLETETHEFOLLOWING BUSINESS OWNER /NFORAWTIfd N. FILE CHECK/F OWNER CURREAMYOivFILEW�EHO Q \� <br /> . ........................................... . ... .............................................................�..... _ <br /> BUSINESSi ....._..................................—_............................... ..HONE ............_..._........................ <br /> .......................................................... <br /> - <br /> OWNER NAME =— J,-/ (/n I(—�Wr/(R/'�• CIO <br /> 1!"=— _---------------------- P -....................... <br /> ................................................. ......First............................. ......:NI_..............__............._............4.4J.t...................................... \ <br /> V <br /> BUSINESS NAME(if different from Owner Name) SOC SEC T TA%ID# <br /> OWNER HOME ADDRESS DRIVER'S LICENSECity # <br /> STATE ZIP <br /> OWNER MAILING ADDRESS (if DIFFERENT from Owner Address) ! Attention:o Care of lop&a /) <br /> Mailing Address City <br /> State Zip <br /> CORPORATION❑ INDIVIDUAL❑ PARTNERSHIP LOCAL AGENCY COUNTY AGENCY STATE AGENCY El FED AGENCY C2 OTHER❑ <br /> FACILITY FILE <br /> FAC1Lm£D# CRO'SiM£D W JKt;CtWN:T£D#� f <br /> COMPLETE THEFOLLOW/NG BUSINESS / FACILITY/SITE INFORMATION: <br /> Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DIVISION T YES ❑ NO ❑ <br /> Is this an Exi STING Business LOCATION but a NEW TYPE Of regulated Business? YES ❑ NO ❑ <br /> BUSINESS/FACILITY/SITE NAME <br /> SITE ADDRESS wV`,'tV/•W C i SUITE Ill i BUSINESS PHONE <br /> CITY f SjATA ZIP <br /> Mailing Address WD/FFERENTfrom Facility Address Attention:or Cara OF(opGona/) <br /> Mailing Address City STATE ZIP <br /> SPC EotsE : ':APDi# . : fks}taTENT_ <br /> THIRD PARTY BILLING INFORMATION: Complete if Billing Party is different from Business Owner Identified above. <br /> ........................._................._......................................................................_.......................--................-.................--......................... <br /> BUSINESS NAME Attention:aCare Of lepton/) <br /> Mailing Address SbS2 � _ // -• _ D_ ! PHONE <br /> Cm <br /> STAyE LP <br /> ACCODNTADD�$sS for fees and charges OWNER FACILITY/BUSINESS THIRD PARTY BILLING O <br /> BILLING AND COMPLIANCE ACICNOWLEDGMENT: I,the undersigned Applicant,codify that I am the Owner,Operator,or arized Agent of this Business,and I ackmodedge that all <br /> PERIIIT FEES, PEA'ALlTES, ENFORCEMENT CTLIRGES and/or NOf1RLY CHARGES associated with this operation will be billed to Is theaddrem identified above as the ACCOLTT <br /> ADD REss for this site. 1 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 <br /> applicable SANJOAQUW 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 /> located C the above facility/site address, I hereby authorize the release of any and all results and environmental assessment information to SAN JOAQUIN COUNTY <br /> EI ONMENTAL 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 SIGNATURE <br /> TITLE DRIVER'S LICEN E# <br /> IpHOTn CDPY InFN <br /> APproyet#By pa#e _ AaaoonfSng Otflae Proaeesing-Completed 8 (£ate :: <br />