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ME 1?�G u a `t rr»,rt"T, a_I Depart <br /> � <br /> 'DATE MORTER FILE RECORD INFORMATION FRGREEN FORMUNIT IV <br /> rf <br /> n <br /> Exnamnaena wa aLlOmOnrr �`OWNERIf7#T'� "yfinYt .L �� C n.. <br /> OWNER FILE <br /> COMPLETE 771EFOLLOWING PROPERTY OWNER INFORMATION: CfEcrI OWNER CLnnENaroNF wmr IID <br /> PROPERTY OWNBL - PHONE L� -- <br /> NAME Q ,y//, <br /> -.� '� I /' r I <br /> 'e M MI art <br /> {N Soo Ec/T"ID# <br /> Owner}{p Ad I.' �L Dar EWs I3m15E# <br /> `' 7 `kKxlt . 1 snSzl9 <br /> Owner MailingA'd , �I ht }' 444 <br /> G r <br /> Mailing Ad C <br /> SM <br /> zip(a^ "y <br /> TYPE OF OWNERSHIP <br /> CORPORATION INDIVIDUAL❑ PARTNERSHIP Cl FED AGENCY n OTHER❑� <br /> FACILITY FILE <br /> FAiu.LTY.ID# `� ` CnossREFLD i Y v`" ' .e tit. 6 t i irk °+3 <br /> COMPLETE THE FOLLOW:YG BUSINESS/ FACILITY/SITE INFORMATION: <br /> Is this a Nm Business LOGTION not previously regulated by the ENWRONMENfAI HEALTH DEPARTMENT? YES ❑ Nq <br /> Is this an ExLsnNG Business Lo mytom but a Nen TYPE of regulated Business Z YES ❑ No �( <br /> 0usme, FA@.xrY/SITE NAME/ <br /> l fn ��I ' � <br /> SDADontess Suarez susw PHONE <br /> 145-13r� 1J. l �YI'4 ice . -70a <br /> fes, <br /> -,� <br /> 'WAR, <br /> , OSUP6i'. R-.,F'� '.'P" A.t ..a P 411i'f?v15, .. 'as.:�... r'"" ! s'r'��'��;;ii <br /> Gr Oil ?; �i '��$.��„`�k� <br /> Mailing Address 1fDLFFERFNT BDm Fadlity lddress Attandan:or Care Of(optional) <br /> Mailing Address Cid_ _ STATE zap <br /> THIRD PARTY BILLING INFO: Complete if Billing Part/ s dfffel-ent fiam Property Owner or Facility Operator idenbl7edabove. <br /> Busmass NAME Attention:or Care Of (optional) <br /> Mailing Address PHONE <br /> CITY STATE zip <br /> AccaunzADoms for fees and charges OWNER FACILITYIEUSINE S THIRD PARTY BILLING <br /> BILLING AND COMPLIANCE ACKNOWLEDGMENT: I,the undenigned Applicant,certify that I am the Ow {(1qe oiorizeddgent of ihu Business,and I acknowledge that all PE2air FFsts, <br /> PervnLnEs,E:vtnRCSnTenTCKurSEs and/or HOfIRLY Gunocr:usatiated with this operation will be `�}�,' X11 identified above as the:lCCotmmAnon6ss for this site I also certify that <br /> all informafion provided on this application is true and correct;and that all regulated a Min s2lordance with all applicable SAN JOAQLAN CO TY Ordinance Codes andlor <br /> Standards and STATE.and/or PEnER.U.Laws ad Regulations. As the undersigned own _{ �pr gent of the pronely located at the above facility/sire address.I hereby authorize the release of <br /> any and all resulta and environmenml asarssment information to SAN JOAQUIN C�VIRONMENTAL HEALTH DEPARTMENT a,smm as it is available and at the same time it h <br /> provided to me or my repreunlative <br /> PLEASE Pa"n <br /> APPLICANT NAME •(,1 {I , A„ L (\. 1,Lt � BIGNATURE <br /> TSTLE 'U <br /> o v.P fr V DRNER'S LICENSE# <br /> f�-�'L.0 N (PHOTOCOPY REQUtHED) <br /> gA <br /> ` ISM <br /> - u `N ex�cYl, t <br /> M.S.. �, <br />