SITE INFORMATION AND CORRESPONDENCE

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San Joa uln County ' bllc: Health Servlces� Ent/ironme 4HealthDivision �r n.,�... _ �. _ - M _ �.�, �.....w FORM {EH 00 15(REVISED 0723197) DATE pG `Q'^ MASTER FILE RECORD INFORMATION SHADED AREAS FOR EHD USE ONLY " " V ~• ¢` UNIT IV OVYNERID s• ^ CASE f �.7 yrF r ;. OWNER FILE COMPLETETHEFOLLOW/NG BUSINESS OWNER INFORMATION., CHECKIF OWNER CURRENTLYONFILEw/THEHD ..........................................................................................................................._.........................................................................................................._...........................------................................. BUSINESS PHONE �If/inn/ OWNER NAME `---------------- --- ------------------- ......... ......................_...............................fr................................._.......M/......._.......................................L........................................ BUSINESS NAME(If different from Owner Name) ^ r _ /�. � �G4 _ /J �, � _ i� SOC SEC/TAX ID# , OWNER HOME ADDRESS {If M, CI DRIVER'S LICENSE# Clty3W I`� V v i/O AI U `�� [l�C� 1(r(r �1..1 �a�( $TATE/P/� ZIP 9 ^� OWNER MAILING ADDRESS (ifDIFFERENT from Owner Address) Attention:ot-Care of (optional) •7 Mailing Address City State i Zip CORPORATION❑ INDIVIDUAL❑ PARTNERSHIP❑ LOCAL AGENCY❑ COUNTY AGENCY❑ STATE AGENCY❑ FED AGENCY❑ OTHER❑ FACILITY FILE FAc UTY ID# ,r CROSS REF ID# Accoumr ID fk-• N COMPLETETHEFOLLOW/NG BUSINESS /FACILITY l SITE INFORMATION: Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DIVISION? YES ❑ No ❑ Is this an EXISTING Business LOCATION but a NEW TYPE of regulated Business? YES ❑ No ❑ BUSINESS/FACILITY/SITE NAME SITE ADDRESS / SUITE# USIT PAEV CITY /) / _ S E ZIP Q Lo Mailing Address ifOIFFERENTfrom Facility Address Attention: or Care Of(optional) Mailing Address City STATE zip SIC CODE. "APN"#" - COhIMENT „< THIRD PARTY BILLING INFORMATION: Complete if Billing Party is different from Business Owner Identifiedabove. ..........................................................................................................................................................................................._............................................................................................................. . BUSINESS NAME , /f Ae�ct�or �reO (1*RakoiG i 1aA4 / Mailing Address / t�L7 / ( pHpr�E le7Q// CITY "^"�� V AccouArrAooREss for fees and charges OWNER FACILITY/BUSINESS THIRD PARTY BILLING BILLING AND COMPLIANCE AC)CgOWLEDGMENT: I,the undersigned Applicant,certify that I am the Owner,Operator,or Authorized Agent of this nd 1 acknowledge that all PERMIT FEES,PENALTIES.£NFORCENENT CHARGES and/or HOURLY CHARGES associated with this operation will be billed tome at the address identified above as the ACCOUNT ADDRESS' 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 JOAQUIN COUNTY Ordinance Codes and/or Standards and STATE and/or FEDERAL Laws and Regulations. As the undersigned owner,operator,or agent of the property located at the above facility/site address, I hereby authorize the release of any and all results and environmental assessment information to SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DIVISION as soon as it is available and at the same time it is provided to me or my representative. PLEASE PRINT APPLICANT NAME v� SIGNATURE TITLE DRIVER'S LICENSE# 77 W ._.._ Approved By Date `" Accounting Office Processing Completed By Data -