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-.,t. s-.. ... yF vrs?.'i'.:1Mf`r4}a�.^, `�%le.s.r.�'��':YJ4`.t^'..iy <br /> a en:"Sa era uirrr� nun tic t lealt t^eiv e Enwronir Health DI islonl= . 'r;=' ,. <br /> f DATE `f� ' ��© 7 MASTER FILE RECORD INFORMATION FORM (EH0015(REVISED071239n <br /> SH. EHO usr ONL, F01NNDhlt1 ASF,iUNIT IV <br /> OWNER FILE <br /> COMPLETETHEFOLLOW/NG BUSINESS OWNER INFORMATION: CHEc)riF OWNER CURREAULYONFILEwiTNEHO <br /> _..................._.............C...._C... lI Iw_ f�yl� a1!�✓'�a_,�Y�(yi_fp��',y-, II/J� i G --,--t--l.�... <br /> ........_.._...__...... <br /> OWNER NAME _______jPHONEBUSINESS �� --- ' — . <br /> ........................_._..._......_....__.................fm..........._....._.._____._.M.......-_'...._._._.._..__....tart................_.............. <br /> BUSINESS NAME(If different from Owner Name) (' SOC SEC I TAX ID# <br /> • OWNER HOME ADDRESS DRIVER'S IJCENSE# <br /> VZIaC- E��"""��V ✓ a.vlrp..�l.lil. �//7�gp(7� <br /> /• <br /> City STATQ _ i 7jP <br /> OWNER MAILING ADDRESS (it'DIFFERENT OwnerAdd/�e f Attention: 7(,opTt/one/J_, / r <br /> A/�A/1C25 YTt) D 7! ` 1�( <br /> Mailing Address City Po Aby- -m2qg —540 !O {a^ i Stat`C-A- i Z1p q-r_A• <br /> CORPORATION tfe INDIVIDUAL❑ PARTNERSHIP C1 LOCAL AGENCY❑ COUNTY AGENCY❑ STATE AGENCY❑ FED AGENCY O OTHER❑ <br /> FACILITY FILE <br /> mr`"'- ,. ;nR&lil' <br /> . FAci'�imt0�:u. :. '��-. ��Caoss REF ID� '�_�,.w?�:,.r�..u.."� :...::Accouircl6+# �. "cr+k+�•�f� .. >,SS,=:w <br /> COMPLETETHEFOLLOW/NG BUSINESS/ FACILITY I SITE INFORmw7o —/ <br /> Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DIVISION? YES No —/p <br /> Is this an EXISTING Business LOCATION but a NEW TYPE of regulated Business 7 YES ❑ NO Er <br /> BUSINESS/FACIUTY/SITE NAME ^M� n G1 _SS•--r / �. \ 1_,t( �' <br /> SITE ADDRESS � ,-, � / i SUITE# Boar(E <br /> CITY I W� lt•-\p__I^- <br /> KScr/4— <br /> POOR ��[`�ZI'P <br /> r . m <br /> Mailing Address i(OIFFERENT(rom FacillyAddress <br /> Attention: or Care Of(optional) <br /> Mailing Address City STATE 7JP <br /> 'ydi <br /> SIGG OoDE°. <br /> THIRD PARTY BILLING INFORMATION: COmplete if Billing Party is different from Business Owner Identified above. <br /> _. ................................................_........__..._........._......._.._..._....._..._. __..._._..__...._......._....................._................._ <br /> BUSINESS NAME i Attention:or Car (ol kanal) <br /> may, <br /> Mailing Address �,f n f/ P�N� V(O?1`r7U� f/0 <br /> CITY :'YZIP q!!-24S <br /> AccouNTAoaaess for fees and charges OWNER FACILITY/BUSINESS THIRD PARTY BILLING <br /> BMLING AND COMPLIANCE ACMNOWLEDGMENT: I,the undersigned Applicsat,certify that I am the Owner,Operator,or Authorized Agee of this Business,and 1 acknowledge that all <br /> PExAffr FEEY,PENALTIES,ENFORCFMFNTCHARGES and/or HOURLYCHARGES associated with this operation will be billed to meat the address identified above as the ACCOUNTADDRES-S <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 FIEDE L Laws 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 mults 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 tome or my representative. <br /> IV _ �p,,� PLEASE PRINT <br /> APPLICANT NAME 1' J �,Ut 1��� yL-4tJ SIGNATURE <br /> DRIVER'S LICENSE ft <br /> TITLE t� ;� IPHnrnrnPY RFouwrnl <br /> -^sx-mea-v.. ... - veu,t•:ct •traa-.m-sr+.-+•_- g°•+--'4Mi�z„"" 'C.ti <br /> G `pfoved By-- ?; ;a ,. "Dale«. v:Aetounting OlficeProcess(rg Completed ti^" ?Y`>.^iret ` .Datey�'. ..<.:, ,^.ax<+i <br />