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{ r <br /> € 2 : <br /> lw <br /> _,. iii kurlt�ltwtltt' <br /> '..tt.: _ <br /> DATE �y a�MASTER FILE RECORD INFORMATION FORM (CH'0016(REVISEo08N9/97) <br /> (1 <br /> SNAO_E).AR,EAUQLJHD WEOMLI - � r_py � -riY.ct ." + rr t� UNIT IV <br /> T <br /> OWNER FILE <br /> COMPLETE TNEFOLLOWINGBUSINESS OWNER /NFORMAT/ON: CHEca1F OWNER CuRRENrtyoNF1LFwrHEHD <br /> . ................................... <br /> Busmesa = <br /> y PHONE <br /> OWNER NAME :------------------- <br /> .......................................................I.........rat.......................................Ml...................^................_...........Laffi...................-................._.' <br /> 9uslNEss NAME(if different from Owner Narne►,,- �-�n Soc SEC!TAX ID# <br /> S f <br /> OWNER HOME ADDRESS Y . wX 2AI r DRIVER'S LICENSE# <br /> City ' /� _ <br /> STA TR (�1 i ZIP q <br /> W Cos <br /> OWNER MAILING ADDRESS (f/O1 ERE/VTfrom Owner Address) Attention: or Care of (optional) <br /> Mailing Address City State • Zip <br /> CORPORATION INDIVIDUAL❑ PARTNERSHIP❑ LOCAL AGENCY❑ COUNTY AGENCY❑ STATE AGENCY❑ FED AGENCY❑ OTHER❑ <br /> FACILITY FILE <br /> lir. l:. �'c,.� rs� .'+:�r b� f. ..::- '' _:_:.. L:�F c v-' .:u r - n. I.rr,•7...+' :SV c._{ 'y [:. <br /> %:�; ., l _':f Y ,••_•:•r.1. J 4 iC.1L 1.T%,1._ h ...:..:'.: {,f 7, .1�� •... ...'-'.� Y' � I. ,.,..... �••:,..n 1 Y r,,..._: '...•'.: , :Yt::. <br /> COMPLETE THE FOLLOWING BUSINESS I FACILITY/SITE/NFORMATio ".•r <br /> I9 this a NEW Business LocArloH not previously regulated by the ENvIRoNMENrAL HEALTH DIVISION? YES ❑ No ' <br /> Is this an ExusTlNa Business LOCATION but a NEW TYPE of regulated Business 7 YES ❑ No <br /> BU81NEsSIFACILRYISITE NAME _I t <br /> SITE ADDRESS l SUITE# BUSINESS PHONE <br /> eA Dri ut <br /> CITYZI <br /> ST E/� <br /> t/--11r tP 7 <br /> Mailing Address if DIFFERENT from FacililyAddress <br /> Attention:or Care Of(optional) <br /> Mailing Address City STATE ZIP <br /> in71G. fll'�.- ,,.,.._?'._.:••._r a. _!.:•: r •_.- �` -t �+ .. :' ,Z�Y '., nr " + - <br /> THIRD PARTY BILLING INFORMATION; Complete if Billing Party isdif�rerentfrom Business Owner Identified above. <br /> ........................................... .......... .... . ..... . ................................................................... . ..............................I........................................ <br /> BusmEas NAME L Attention:or Care Of (optional) <br /> �"1 Vn qri <br /> Mailing Addressr Vn PHONE)ll <br /> CITY �c o�V <br /> g . STAT ' <br /> AccouNTADOREss for fees and Charges OWNER FACILITY/131USINESS THIRD PARTY BILLIN ` <br /> BILLING AND COMPLIANCE ACKN0WLEDG?1ENT: 1,the undersigned Applicant,certify-that 1 Am the(honer,Operaror,or Aulhorrzed Agent of Ihiq Business,and I acknowledge that all <br /> PFRAAT FFFC.PF,AAI.TIRY,EA'F0Rc&WFNT01.1RGES and/or KouRI-T CII,tRGEti associated with this operation will be billed to me at thea identitied abw�e a,the AC'CUL'M'1DDFE.S'.S <br /> for this sloe. I also certify that all informal"provided On this application is true and correct:2nd that all regulated activ'iti"wi pPT'fntTtlPd In aeCnrrlAncr w;tb all appikable SAN <br /> JOAQUIN COIIN IN Ordinance Codec and/nr Standards.and STATF and/or f'CDERAL Laws and Regulations. As the undttsigned. er, 5er�f r,or agent of the properly locotEY1 al tfie <br /> above facilityAite addrevs. I hereby aurhorive the release of any And all results and en%ironmental assessment intormation 4 AQI'I,'CC)I IN,Y ENVIRON TENT,\l. <br /> HEALTH DIVISiOIN ns soon as it k avallable and at the same time it is provitied to me or my representative. <br /> PLEASE PRINT <br /> APPLICANT NAME S SIGNA <br /> TITLE tJ( DRIVER'S LICENSE x <br /> (PmnTnrnFy pro nprn) <br /> pl?01►t1d�fy `_. `' - I +Cie: ,.',s �..:: :'1°iauoitirtlrtctt�liiit?8 E� Btfl _ t�S#.�:E�G <br /> d LNO�I� fJb1i��@! L66 l-Vc,-6 <br />