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N w s <br /> Sart.incl"�I�r County " ��FsaE S�ce� ��nmie k�t#[zzt� , �.... <br /> X DATE <br /> ASTER FILE RECORD INFORMATION FORM (EHODIS(REvlseo DBHsls T) <br /> 9xaom me PmaEHeueOxv - °O <br /> UNIT IV <br /> OWNER FILE <br /> COMPLETE THEFOLLOW/NG BUSINESS OWNER INFORMATION. CNECXIF OWNER CumrENrcroN,;xEWrHEHO <br /> ......_. ........._................._......................_._...._..�.._-- <br /> BUSINESS i HONE <br /> OWNERNAME _____________________ .________-----_--_ i <br /> .........................._........_................._._.._... _—. <br /> BUSINESS NAME(If different Atm Owner Name) j SOC SEC/TAX ID• <br /> x! OWNER HOME ADDRESS ? DRIVER'S LICENSE <br /> # <br /> ' i STATE i LP <br /> OWNER MAILING ADDRESS (WDIFFERENTfrum Owner Address) Attention:or Care of (opdbu/) <br /> Mailing Address City i State ZIP <br /> /\ CORPORATION❑ INDIVIDUAL❑ PARTNERSHIP LOCALAGENCY❑ COUNTY AGENCY E3 STATEAGENCY❑ FED AGENCY❑ OTHER <br /> FACILITY FILE <br /> F, iTTYtlrx CRDS$REPie# .: 14tCODNa3ikiR' r. , <br /> COMPLETETHEFOLLOWING BUSINESS / FACILITY/SITE /NFORMAvom <br /> IS this a NEW BUalnee,LOCATION not previously regulated by the ENWRONMENTAL HEALTH DIWSION 7 Yes ❑ NO eY <br /> Is this an EXISTING Business LOCATION buta NEW TYPE Cf regulated Business 7 YES ❑ No <br /> XBUSINESS/FACIUTY/SITE NAME <br /> V SITE ADDRESS SUITE# BUSINESS PHONE <br /> r <br /> CITY STATE i Zip <br /> Mailing Address WGIFFERENTfirom FacffifyAddrass Attention:Or Care Of(Opbanal) <br /> Mailing Address City i STATE Zip <br /> =77 <br /> THIRD PARTY BILLING INFORMATION: Complete if Billing Party is different from Business Owner/dentKed above. <br /> BUSINESS NAME AtteIRIOn:orCare Of (opGDNW/ <br /> Mailing Address i PHONE <br /> CITY STATE ZIP <br /> ACCOUA?AODRFSS for fees and charges OWNER FACILITY/BUSINESS THIRD PARTY BILLING <br /> BILLING AND COMPLIANCE ACI OWLEDGArFM: I,the undersigned Applicam,axify that I am the OHwer,Operator,or.{yrhortzed.-Igen,of this Business,and I admowled ge that all <br /> PER.NLT FEET, PENALTIES. ENFORCEMENT CMAR(.ES and/or HOURLY CRtRCES associated with this operation will be billed to me at the address identified above as the ACCOUNT <br /> ADDRESS for this site. I also cenifv that all information provided on this application is we and correct; and that ail regulated activities wilt be performed in accordance with all <br /> applicable SANJOAQUDY COUNTY Ordinance Codes and/or Standards and STATE and/or FEDER.V.Laws and Regulations As the undersigned owner,operator,or agent of the property <br /> located at the above facility/site address, I hereby authorize the release of any and all results and environmental assessment information to SACT JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DIVISION w soon as it is available and at the same time it is provided to me or my representative. <br /> PLEASE PRINT <br /> APPLICANT NAME XSIGNATURE <br /> TITLE DRIVER'S LICENSE# <br /> i /PHrITn(•OPY gFO111q Fnt <br /> Appruyad Bjp .:.cA,.��: ..s.? .° . ' Acaovn47ng t1Rlee Proeeeatsrg Compte}@a8y :'.. Data ':_ <br />