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'J'R. .:✓ ,aim�.earrc .,_ - T-.;YAWw.. n-- tatfi.-.r,.J":.v.�1gvp. . +n.,m,,.. ,— <br /> � Sar .toa'"mfm orJn 61 Heartervtce Envlronm IfisalttifrDlvlslo f + <br /> 'A DATE �'� FORM (EH00t5(REv,Eo07a3n7) <br /> ;., © � MASTER FILE RECORD INFORMATION <br /> annnEo waEAe Toa EHD vee OaLe OWNF701D , ASQ. UNIT IV <br /> OWNER FILE <br /> _COMPLETE TNEFOLLOW/NG BUSINESS OWNER INFORMATION: CHECKIF OWNER CURRENTLYONFILEWT/EHD <br /> ................................................................_.__.._..._.._....._._..---....__........T............ <br /> .—_._.._._._..._..__..._........._ <br /> i BUSINESS ' •••_.........._.... <br /> ;C.C ----�I Iwl`t _ <br /> ------j PHONE G / 2 / r� -•••, <br /> OWNER NAME — --- �---...__--_ �/q�rJ//� /�`C—fes• <br /> ............. _..—..__........_' <br /> BUSINESS NAME(If different from Owner Name) ; SOC SEC I TAX ID IT <br /> r <br /> =: OWNER HOME ADDRESS DRIVER'S LICENSE# 9 <br /> ,i. cm LP �5 <br /> OWNER MAILINGADDRESS (i/O/FFERENT/rOm OWnerAdde J Attention-ol-Careo (opthanal <br /> 1,AAncn �'�Ei P 7-T <br /> lar �P'�� <br /> Mailing Address City P® BSZC ���—702g9 [ Sta ': zip <br /> CORPORATION 82'r <br /> INDIVIDUAL❑ PARTNERSHIP 0 `'/LOCAL AGENCY❑ COUNTY AGENCY❑ STATE AGENCY 13 FEL,AGENCY❑ OTHER`❑J'�?' <br /> FACILITY FILE <br /> :�ia�,w- r�, - <br /> �AGIUTv?lO.#aY h tz�t Clzoss�RE>wID•#�ft* .0s.-"�'s y' ..�AccdD "6/i.4._, <br /> COMPLETETHEFOLLOW/NG BUSINESS/ FACILITY/SITE INFORMATION.' —/ <br /> Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DIVISION? YES No ❑ <br /> it Is this an Exu nNG Business LOCATION but a NEW TYPE of regulated Business? YES ❑ No <br /> : BUSINEss/FACIUTY/SITE NAME <br /> SITE ADDRESS ( SUrTE# ! BUSINESS HONE �' <br /> CITY 5� sT2TE ZIP <br /> G <br /> rr 4. <br /> Mailing Address ifDIFFERENTfrom Facility Address Attention: or Care Of(optional) <br /> Mailing Address City ; STA�T,E,�{ ? ZIP <br /> THIRD PARTY BILLING INFORMATION:.Complete If Billing Party isdifferentfrom Business Owner Ident�edabove. <br /> ................................................................_......................_................................._....................._................................................._...............____._..._......................................................... <br /> . <br /> BUSINESS NAME L (� r, `: Attention:rar Care Of (al)&'Ona/ <br /> fi01tlF1AA2�F .� }y1.h.lO ,I� ;� L-- <br /> Mailing Address ('] PHON%)C? <br /> U /'L oca ! Tlo7 riU 30 <br /> CITY <br /> c� /1fL'RMr.1rt N/Ijgai : ZIP 9✓ ]I <br /> ccQWAoDREss for fees and charges OWNER FACIUTY/BUSINESS THIRD PARTY BILLING 1 <br /> BD.LMG AND COMPLIANCE ACKNOWLEDGMENT. L the undersigned Applicant,certify that I Am the Owner,Operator,orAuthorl,edAgnd of this Business,and I acknowledge that all <br /> PERMIT FEES,PENAL77F$ENFORCF.NENTCHARGES and/or ROURLYCHARGBS associated with this operation will be billed to me At the address identified above m the ACCOUNTADDRESS <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 FEDEluL Laws and Regulations. As the uadersigned owner,operator,or agent of the property located at the <br /> above facility/site address, I hereby authorize the release of any sad all roults 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 /> J PLEASE PRINT <br /> APPLICANT NAME / � t SIGNATURE <br /> TITLE D t� DRIVER'S LICENSE IT If/YL 1 S <br /> (PHnTnCn PY RFOI IIRFDl <br /> moved Byti MOM* <br /> y - = ntin Office Pioc ss'IY"sCom ted' •+ �� sir;'?"T�' . <br /> g. rtg�p a <br />