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r" a Joa cal ' :Gountt •, 1rG, cart °sSemce nVironme "Ffiea[t.MM'S $ <br /> FORM (EH0015(REVISFD07M&I,7) <br /> DATE MASTER FILE RECORD INFORMATIONIW <br /> EHD O <br /> tiq,. w3 UNIT IV <br /> 3 <br /> rr b50d. OWNER FILE 070q-jd-, <br /> C.........................................................._..._._._._._.._.._ __ _......_...T........._.._................_._.._�.._.—__.._._._ ............._.._....._......__._.............._...................-'-- <br /> BUSINESSHONE <br /> OWNER NAME ____/_J___________�___�____l.i__________�_____ P <br /> ....._._ <br /> ...........................................................iY............. <br /> _.r..._._ ....M_._..�__...._____.�.....la%..._... _......._.. 7 <br /> BUSINESS NAME(If different frau Owner Name) y { /L SOC SEC/TAz ID# <br /> OwwFRHOMEADDRESS J i11c /V� �y�r/ + DRIVER'S LJCENSE# <br /> any <br /> 7 11/�i/(�",^ Gd T�✓� L ��C f.7r STATf��- TJP 9sZaZ. <br /> OWNER MAILING ADDRESS (1fD1FFEREA?frem Owner Address) i Attention:wCare of (optional) <br /> Mailing Address City �vtY� ; State Zip <br /> CORPORATION❑ INDIVIDUAL❑ PARTNERSHIP❑ LOCAL AGENCY O COUNTY AGENCY❑ STATE AGENCY O FED AGENCY❑ OTHER❑ <br /> FACILITY FILE <br /> '; <br /> ,.. �`� •it Ca ssREFI /It:ccdttslD; " ..M' t�'s..'$* .'mf"' .'". <br /> mac <br /> COMPLETErHEFOLLOWING BUSINESS I FACILITY i SITE INFORMATION: <br /> Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DIVISION? YES ❑ No ❑ <br /> Is this an EXISTING Business LOCATION but a NEw TYPE of regulated Business? YES ❑ No ❑ <br /> BUSINEss/FACILITY/$ITE NAME /_7O /1 �q/JT_I �I,�,VD� <br /> SITE ADDRESS ((/!•� �/r/KJ(UI IYJ I�, j SUITE i BUSINESS PHONE <br /> &2D Nmni <br /> CITY IZ/ 'l i $T!✓ ! ZIP <br /> �S– <br /> Ey1Sii77777= <br /> Mailing Address ifDIFFERENTfrom Facility Address Attention:or Care Of(opLdnaf) <br /> Mailing Address City STATE ' ZJP <br /> AN � – }- <br /> Pre .C7O'...ME;N �SM <br /> �.. e. <.e. ...,...>..-�. <br /> THIRD PARTY BILLING INFORMATION: Complete if Billing Party is different from Business Owner ldent�ed above. <br /> ......................................_......_...........................__........._._..........._..._.........._.............._................._.............._..._.........._................................................................................................... <br /> ; <br /> BUSINESS NAME ? Attention: O�f�OarE tilt (OQt%an�^eQ� <br /> Mailing Address % PHONE <br /> CITY 5'-�/'G/�Z!/� ' S '7jp <br /> AccouArrADoaEss for fees and charges OWNER FACILITY/BUSINESS THIRD PARTY BILLING <br /> BILLING AND COMPLIANCE ACXNOWLEDGNENT: I,the undersigned Applicant,certify that I am the Owner,OFermor,or AmhorizedAgent of this Business,and 1 acknowledge that all <br /> PExwT FEFs,PEvALnEf,ENFoRamEvr CmAGET and/or HOURLYCYARGET associated with this operation will be billed to me at the address identified above As the ACCOUNTADDRFM <br /> for this site I 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 applicable SAN <br /> JOAQUIN COUNTY Ordinance Codes and/or Standards and STATE and/or FEDERAL taws and Regulations. As the undersigned owner,operator,or agent of the property located at the <br /> above facility/site address. I hereby authorize the release of any and all results and environmental assessment information to SAN JOAQUIN COUNTY ENVIRONMENTAL <br /> HEALTH DIVISION As soon as it is available and at the same time it is provided to me or my representative <br /> '_--�-7) PRINT <br /> APPLICANT NAME SIGNATURE <br /> TITLE DRIVER'S LICENSE <br /> J IPNr1TflMPV RFOIIIYFnt �T; <br /> �'ACCOUntlrgOffice Process <br />