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1 <br /> DATE �' MAS ER FILE RECORD INFORMATION FORM IEH0015{REV98Eb06111/97} <br /> UNIT IV <br /> OWNER FILE <br /> COMPLETE THEFOLLOWING BUSINESS OWNER INFORMATION: CNECK/F OWNER CURRENTLI'OHFILEWITHEHD <br /> .......................... ... . <br /> BUSINESS ..................................._.-.......-.... ..-...-......-----.....-....-......--..-..--.....--.....--......--......--.-.-..... <br /> PHONE <br /> OWNER NAME --- -- --- -•_—-•,----—-----^——'^—^--- <br /> ...................................................................First-..........-.........- .....M!................ .......4eS4...-.........-.-........-............` <br /> BUSINESS NAME(If different from Owner Name) _ SOC SEC 1 TAX ID# <br /> i OWNER HOME ADDRESS .. DRIVER'S LICENSE# <br /> t*tv <br /> i STATE E ZIP <br /> OWNER MAILING ADDRESS (if0/FFERENT*vm Owner Address) :E Attention:orCare of (00-1-9 <br /> Mailing Address City ? state ¢ <br /> CORPORATIO INDIVIDUAL❑ PARTNERSHIP❑ LOCAL AGENCY❑ COUNTY AGENCY❑ STATE AGENCY❑ FED AGENCY❑ OTHER❑ <br /> FACILITY FILE <br /> �. <br /> COMPLETE THEFOLLOWING BUSINESS /FACILITY 1 SITE INFORMATION:,, <br /> Is this a NEW Business LOCATION not previousty regutated by the ENVIRONMENTAL HEALTH DIVISION 4 . YES ❑ No ❑ <br /> Is this an EXISTING Business LOCATION but a NEW TYPE of regulated Business 7 YES ❑ No ❑ <br /> BUSINESS/FACtUTYfSiTE NAME ,,A 1 <br /> SITE ADDRESS , /` � /� SUITE# BUSINESS PHONE <br /> CITY 1, - $T Tg ]JP <br /> Mailing Address ifO1FFERENTfrom FaeilltyAddnKs ? Attention.or Care Of(optional) <br /> Mailing Address City STATE ZIP <br /> r .............................:.- .. <br /> .............: <br /> ..,,, ..........:::....... .:fi4tNtII�1ft3" ..... ..:.....,:..v::: ::: <br /> P 9 Party _ ......... ..... .... <br /> THIRD Putti BILLING INFORMATION• Complete if-Billie! Pa l,8 different from Business Owner Iden6fred above. <br /> ...........--•----- <br /> .1 <br /> BUSINESS NAME 2 <br /> Attention:or Care Of (optional) <br /> Mailing Address /7• PHONE()- / <br /> CrrYrr-n f 1 J <br /> STATE Z1P 9.? <br /> ACCDUA/TADDRESS for fees and charges OWNER FAc1L1TY/BUSINESS: THIRD PARTY BILLING <br /> BILLING AND COMPLIANCE ACKNOWLEDGMENT: 1,the undersigned Applicant,certify that I am the Ownej Operator,or Atuhori;ed Agent of this Business,and I acknowledge that all <br /> PERMIT FEES, PENAL77ES, ENFORCEMENT CHARGES and/or MDURLY CHARGES associated with this operation will be billed to me at the address identified above as the ACCOUNT <br /> A))AR,ESS 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 <br /> applicable SAN JOAQUIN COUNTY Ordinance Codes and/or Standards and STATE and/or FEDERAL Laws and Regulations. As the undersigned owner,operator,or agent of She property <br /> located at the above facility/site address, I hereby authorize the release of any and all results and environmental, assessme t information to SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DIVISION as soon as it is available a at the same time it is provided to me or my representativ <br /> xAPPLICANT NAME �ze .ma y _ — SIGNATURE • <br /> ' TITLE a �.AA 8— . '�'T`"' �i/4 DRIVER'S LICENSE# 2 a� <br /> .:::,........ <br />