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.: aWddo u FritCofflita rciReaIttWendde" w nme " a .eat. lvrsion °r <br /> DATE V MASTER FILE RECORD INFORMATION <br /> FORM (ENWIS(RE�072397) <br /> -�° �°�• _ UNIT IV <br /> OWNER FILE <br /> Compu7ETHEFOLLOW/NGBUSINESS OWNER /NFORMA770N.' CaEwar OWNER CURaImmyarpLewm emo ❑ <br /> BuslNEss PHONE <br /> OWNER NAME <br /> BUSIHESSNME(Ff&Wrc tfromOwnw Nt e) /fO / /1� SOCSEC1TAx ID• - x <br /> OMEN HOME ADDRESS �nc//+��_-�/—( �AA�'F' (�I /:� � ORIVE111'151JtEMSES <br /> Ghr S�G en t�R- I ALJ STATFCer € TJ► . 9sZaz <br /> OWNERMAtuNGADOREss (ND/FFERENTfrom OwnerAddrsv/ ' ACetdion:a'Cars of(opNona9 <br /> Mailing Address City i State Zip <br /> CORPORATION❑ INDIVIDUAL❑ PARTNERSHIP❑ LOCAL AGENCY Cl COUNTY AGENCY❑ STATE AGENCY❑ FED AGENCY❑ OTNER❑ <br /> FACILITY FILE <br /> `FA ,D� 1Ha0ssREF1 AccouNslD:Q .I:._. <br /> COMPLETE THEFOLLowiNG BUSINESS/FACILITY/SITE/NFORMAnom <br /> Is this a NEw Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH OrnsION? YES ❑ No ❑ <br /> Is this an EwsTlNG Business LOCATION but a NEw TYPE of regulated Business 7 YES ❑ No ❑ <br /> BL1WNESS/FAaLrry/SRS NAME <br /> Srre ADOREss s # BUSINESS PHONE <br /> AD <br /> Sc2z <br /> cm sL / i STy�€. ; zip �75Zas <br /> Rn„ rm iT�E�G 7 cG rta'1 z Tw�N�C D � KEi-t^�'. k'y x• -�G,.'�'+5'S�:Y �-.7� .-".... ��_ 7"" . <br /> Mailing Address ifDIFFERENTfrom FacilityAddress Attention:or Care Of(optional) <br /> Mailing Address City STATE ZIP <br /> THIRD PARTY BILLING INFORMATION: Complete if Billing Party is di(ferentfrom Business Owner(denbWedabove. <br /> BuslNEss NAME ,/ � �e G I 1 I� E Atlantlon:arCare ( 6� lona/) <br /> Mailing Address mD �x f2 PHONE <br /> ZP <br /> AccouNTAooRess for fees and charges OWNER FACILRY/BuslNEss THIRD PARTY BILLING <br /> BILLING AND COMPLIANCE ACRNOwLEG . I.the underaigued Applicant.certify that I am the Owner,Operator,orAwhorizedAgent of this Business,and I admowiedge that all <br /> PEFAn7FEES.PENALT=ENFORCEME ]"CRAEGFS and/or RDURIr OmRGES as ted with this operation will be billed to one at the addrm identified above as the ACMVNTADDRESS <br /> for this site. i also certify that all information provided on this application is true and corse:and that all regulated activities will be performed in Accordance with all applicable SAN <br /> JOAQUN COUNTY Ordinance Codes and/or Standards and STATE mod/or FEDa L laws and Regulations As the undersigned owner,operator,oragat orthe property looted at the <br /> above facilitylsite address. I hereby authorize the release of any and all results and mvironxramtal assevmeat information to SAN JOAQUIN COUNTY ENVIRONMENTAL <br /> HEALTH DIVISION As soon As it is available and at the same time it is provided to rue or my represauadve. <br /> PRINT IV V <br /> APPLICANT NAME SIGNATURE <br /> TITLE \/ DRIVER'S LICENSE <br /> / IRKfTrff°PY RPOInRPnI <br /> O <br />