|
/2001 09: 27 20946F -33 FIFTH FLOOR PAGE 03
<br /> 02/
<br /> .......:.....:.:
<br /> ..S.J.vr.}.:YxS•.!ti�.:.4;{.:.^�.::.:S.?`,ii::i:.:.i,':::..::;}n..\...4...,;t•'..i+..�t.:.N:..:.:.�a}._s..:.,..S.fy•..:i.-\.:.}:'.::.:.:.:AAF...:F.::..f+..y..i:.�t........t...1..#.....�1:..:::.:•<.,�.,_..�,:E..:k.:.•U.:.:.,.€....r#..:..,.,..:..:.f.:..._..};,.:?,{,...„.::..,�.'.,-:#..��...�......:...:'-.:.::C-.;•...::'.;::.-:->;..Ei
<br /> 5r-
<br /> .:.�.+.:�.:.•:.f.'�;.�:.;`.:;:.•-.w•fpr.:-:.r::...::}.r::.;r;f-^.fi-r-;-:.,..,LJ:..•,.S.;y.
<br /> ,:.y,:.mo;i:...,.-..•}:}.:.r.:.;.:�..;.�..:�.i.»•..-:F%.t4..:.rA.>.....:-.r..:r.
<br /> ...-,;,•.;.T.•.'.-,i...wr.,Y.r.',?:':...:.R"-R,:-:::.'.s.:x..t:-...F...:+;.}...�.;s:...,.•..�:.......:::rn,%.v:'.::i5".:•:.',^:�.a..::.�5:.i4::i.:.}u::;.•:'::c:;:n}
<br /> k::.;`•R•:+.+i.
<br /> ::.{t..L.+_ s... ... ...... .......:... :..::::::..�!7 :.::..::...::::::.:: .----:.. .. .::..r.::.r.r::•:::.:�..... FORM (EN 0015(REvtlED06H119T)
<br /> DATE Z U MASTER FILE RECORD INFORMATION
<br /> r >.<:� :yzr, _jam r:: }. z .....•;:,
<br /> UNIT f
<br /> �NAa60 "E— END UaFONLY ,:..j. ••.
<br /> } xv
<br /> :
<br /> r m�a{t
<br /> _ OWNER FILE
<br /> CHECKIF OWNER cuRREIIITLYONFILEW/THEHO
<br /> COMPLETETHE FOLLOW/NG BUSINESS OWNER /NFORMAT/m .......,...............__._..___._._....._.........;.__.---_._.__..._._._........._.._.............___._....___.-_._........._.-...;
<br /> .........:............................_..._........._._...___._.__.........._,_.._..-----._. _..
<br /> ........._. C
<br /> PHONE
<br /> BUSINESS i - •�••• , r�L-(L2J�v�Js
<br /> _--------=-
<br /> .......... ---� -------------------- (�v S� 94 F- 7
<br /> OWNER NAME _•-_(fit..._.._......_._...
<br /> _.....
<br /> __----..--.._ ..........�fI............._......------------
<br /> SacSEC lTaxlO#
<br /> BUSINESS NAME(If different from Owner Name)
<br /> N
<br /> CCA
<br /> / C �+ (o I Q-7 DRIVER'S LICENSE#
<br /> OWER HOME ADDRESS L S [ 1 /
<br /> City — STATE C yqZIP
<br /> J
<br /> OWNER MAILINGADORESS (ff0/FFERENTfrom OwnerAddresm) Attention:or Care of [ppliortaQ
<br /> Staff ZIP
<br /> Mailing Address City
<br /> CORPORATION 13 INDIVIDUAL 11 PARTNERSHIP E3 LOCAL AGENCY 13 COUNTY AGENCY 0 STATE AGENCY FED AGENCY OTHER 13
<br /> QQl�2 `7 FACILITY FILE
<br /> ... ... ; ..+ u:..--.:,,:a:- -`r:-: -i-::;r.:y :^%;'s'-• YY.' -"-=7'!1. :•^'T�•':{}y
<br /> ... .......: ....:r.. .• ;•Sw•••: v.:-:••;: f-'r_-.._,{•::5:+/.- •'J.•- 'Y4: ..Jf:+ R�nSI:: - d`
<br /> .._... :::::::-:.::.. .:.. ...:.. vw , .- .v:.,...- :.,n. ...•:..>!_- ;-v n- `{:'yY- Sv... 4.. :•':\:.} _ �?Y rY/{:
<br /> _.n..}. _ ..w -}{x;.4 .}.:•. }.>:::-+5..�.r i,-y }: ` " -LYPi...:r•Aa:�:: :4:~ :LiC-Mi'' :? x�,{r. "M
<br /> R=
<br /> •�r:
<br /> ..:-.ni i�w:-. .yy,. � {'i�(:A: •� .0 -Qti,2L: '."�Y :.:�" �d.,�.- � �}� ...�'h_ t.}Y.
<br /> ✓.-�.#.-{�`�}7F�1 .:i y:x;a •.,.�. � '.tY+�.a{ }J���y�n gyp( _ i°;l:S-:?;-.`w::,;„ �i.��� 'tN.; t�t�_,C':i�•^-.-.v.. �T"n:�'--fix: ::'
<br /> �..; :,: :}+:k.:1-:�iY2:{:}�O..Y•}':3:1�%•MuVl.IiT:O•:i����OF?,.:-0�},..•'S:-�:+' .. -_-•-?..-....... ,
<br /> COMPLETETHEFOLL0WING BUSINESS I FACILITY/ SITE /NFORMAVON. �y
<br /> Is this a NEw Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DIVIslow T YES 0 NO `q
<br /> Is this an EXISTING Business LOCATION but a NEW TYPE of regulated Business 7 Y'Es ❑ No,9t
<br /> BUSINESS/FACILITYISITENAME C, ( �-�C�S �-t-. o� c� �-'� +�/y t,
<br /> —i
<br /> 11 O/ H vv/ 1 p �' co }^ �c� , /(�+ti G c./ ! SUITE# i BUswESs PHONE
<br /> SITE ADDRESS yt 7i, T ir��.�{ {9� Y 1 1 f
<br /> Cm �t� � �c✓l[ c( �cdclrt5 5 ST�d ZIP
<br /> .....:,.:._�:::. �-:.�._...-. •;:::t-,::,-:.::i :�-'-+rar:.�-Y-Y`::x::Si%::i-::k:•';:�<:Gu:.w$4n• :moi .''3':_ •'Girj%'�f`:a^�.�,':%� .'::ke::uS:Li;:
<br /> }}S",.:;;,., f .;:rC:}`.-}� _ A•�.i:-^{�",}.�'ir�-"i'tii$:}•vi!.i.•:}':+:;:r 4•{,{' O• - ',7"^�+,::v^•F �'C4:1• U'.t�:}:`.
<br /> -.. .S-::}:y;..�;,�,^.'^'tt.ir4::;ii.,•;,.+2. .v.r}i}`::•\S•.Ak.}:::�1 r v.i.;•..,.,-. �.".�S•' C�,'�.��Y�C�;.::r-/.C.;ry -�vJ
<br /> ....,.::,. :..r:G -....\'Lu'::::...::.r. .}... :'-^: ::•:... '%�.k�:YF:�� ?-.-Lv,-92:Y ,...�y.�{<,. .r7f;.-,.}v;.,} t<'2,-;.[,,.:...r_}...;...,...:. _ _
<br /> :::::':-•:::I�::..:.8,rc.•Y ,. -.o. •::., rtr .,:3:.:...>). :..r..:....+::;.. ..., i :� L�^' Q- iw;t-r :;�Y7;•:}. ,+ ci-.e,•-,,. •a..vd. . .� •r:}...
<br /> r. ..t......; .4.w:}.;::.:.'.v-\�:-'('.,; !;- :. -(t 1`.;f•Y s: i ..}n n'�.�htiC YH.^::.i...:•- }i:?:f-.t9{41:Y•
<br /> Mailing Address if OIFFERENTfrorrl Facility Address ? Attention:or Cara Of(optional) r
<br /> Mailing Address City 1433
<br /> 433 c.� �C A P
<br /> ...............+-:::.:/::•. :.:.,..::�-::•--:-.,...,;/V.•:.'••.:.-."�.:;-:;:+i:v:;=__ ':t :}>yt{' ti� - - ..��,r�•-v•;c}3.�.£.'t9%;.a::`,w�kr'}.;v��'rS+t`L :•.J::b]{fi��4 >�-`:{�S
<br /> .,:?}`':{.: •.4'i. 1::..r...a�.2,.,t•.} 'GYn.�}:s}: rx#{.y_.;}_,. �i}`{,t,: 3 %�' S.{i .•',�,..`,i�uv ,Y � `� - ,.:C�",+?. .,�: %,�
<br /> x{r:{::; c ;::$`<:.: _ ..;1{, lC: •.:r.--;:} r'4{:r:'i}. 9:•' ::rx>r.:` ".9• 'L .-�;�..:-}�'.: 44:-r,.;•• -.,.7.: :la'�+:Y:�Y?�:t. �x
<br /> ,�tt �!, i5�'"i:. _r.'r:�;},:,���'•-, :.->»' ':a`.'o`x:' -� -:;:Lc'E i. ••(; #%%;<$,'�'ypfi4d.'r:>.v:.$£•::., .•si:-,c
<br /> •a�,l.f' '..-...b.^^fA�S<J{::FN;:jI.`Sf:yS,:{p:::�ii:.' R:i;U�A� '�i�''i��r•.x✓`�t."�:-..�"Yt�'ii^tia
<br /> THIRD PARTY BILLING INFORMATION: Complete if Billing Party is different from Business Owner Identified above.
<br /> ..................................................._................-••...._..........___..._.......
<br /> _
<br /> BUSINESS NAME Attention:or-Care Of (opt3fonal)
<br /> 1 1
<br /> PHDN
<br /> Mailing Address 3 f Ef c / 1 �, 3 3 �'
<br /> CITY /v STA (�1 ZIP/ g 3
<br /> ACCOUNT A20RE53 for fees and charges OWNER F=LiTYIBUSINESS THIRD PARTY BILLING
<br /> BILLCIG AWD COMPLIANCE ACKNOWLEDCME'IT: 1,the undersigned applicank certify that I am the Owner,Operator,or Authorized Agent of this Business,and I aclaowledge that all
<br /> PERMIT FEES, PENALTTES. ENFORC&NENr CWGI:S and/or HouRLr CRAAGEs associated with this operation will be billed to me at the address identified above as the ACCO
<br /> RESS for this site- 1 also certify that all information provided an this application is true and correct; and that all regulated activities will be performed in accordance with all
<br /> applicable SAN JOAQUL�I COINTY 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 at the above facility/site address, I hereby authorize the release of any and all results and environmental assessment information to 5?..V JOAQUllV COUNTY
<br /> ENVIRONMENTAL HFULLTH DIVISION as soon as it is available and at the same time it is provided to me or my representative
<br /> LEASE PRINT
<br /> 51GNA RE
<br /> APP NTNAME /✓ic/t0/ �} L Usk
<br /> 'oc. DRIVER'S LICENSE# 7
<br /> / T
<br /> TITLE �L=U L O G { S T— _y. ..orris ��C��pZ
<br /> :a}r::.:;.:.:-:+:}}:x•:;::aa:::::n:;a}<;;•},!;;}:::: :oc fix}}},::,_(,�,�",^'.ii:,3r+' :5:5:
<br /> ..n...:r... ........ Vin..•.....•....,,,....v.... ... .... :.,.::.]........:...r........... ....... ... ;:..i {:�LFQ
<br /> ,.:i4•.:.:.::«. ..t.{.:.,:.,::,::.}r}'::. -:".•.:; .:..>:;;:::..::::::,..}::-.........�-.,::,. ::' f3ffiae;lrr+oaessta f?. � kf{}:...: ::: a: ..t•::
<br /> RP.raycL���i;§ �'rc;"sik,`::,'':�+k.^?:;::. a `'`:<�::^:�:i:::::..f.::%t'}::: :.•11��C�n��
<br /> � �
<br />
|