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�.Fswf�" mss,;_. �..^_""'�q"�. '- .-.`u�7`�'�".i�'gf?'�a'. _.. .:. "'.,�'•'°"w""�'.....r.«":#,..R'^'?"""',a�n <br /> w ."San `oa utn oCun� tib ICrHealtFS'enrtce Envlconmentaiealth .Dlvlsiorr f -g' <br /> 5' DATE `k FORM (EH 00�5(REvISFD 0723/97) <br /> 11 <br /> MASTER FILE RECORD INFORMATION <br /> NORUNIT IV <br /> SHADED AREAS FOR EHD VSE ONLY <br /> ' OWNER FILE <br /> COMPLETETHEFOLLOW/NG BUSINESS OWNER /NFORMAT/ON.- CHECK/F OWNER CURRENTLYONFILEwn-HERD <br /> .: <br /> .........................................................................................................................._.........................._...................._......................................__._.._......_..........._............................................. <br /> , <br /> ;. BUSINESS �-1 0 / PHONE <br /> .l/v <br /> OWNER NAME "'-----------------------�------ -------' ; <br /> ................................._................"..............F.rst................._......._...__.....k1.._...._.........».» . .................Luit.._.._....-.......................... <br /> ' i <br /> BUSINESS NAME(If different from Owner N me) SOC SEC/TAx ID# <br /> OWNER HOME ADDRESS DRIVER'S LICENSE# <br /> City <br /> STATE Zi P <br /> OWNER MAILING ADDRESS (if DIFFERENT from 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 /> ¢_FACT ID`s !..> s� ..EROSS`REF IDS »k?+�. t.,a a ss ACCOUNZIDkPzw. n F� Vi <br /> COMPLETE7-HEFOLLOW/NG BUSINESS/ FACILITY/ SITE /NFORMAno <br /> Is this a NEW Business LOCATION not previously regulated by the ENVIRCNMENTAL HEALTH DIVISION? YES ❑ No UL <br /> Is this an ExISTING Business LOCATION but a NEW TYPE of regulated Business 7 YES Nam <br /> BUSINESs/FACILI ITE NAME <br /> f <br /> SITE ADDRESS �� � i y� �„ _ � � ^ I SUITE# BUSINESS PHONE <br /> CITY $Tq'(E„ � ZIp <br /> �—^Llf <br /> Mailing Address if DIFFERENT from Facility A ddress Attention:or Care Of(optional) <br /> Mailing Address City STATE zip <br /> �,T'.i�iS2�,.�'..:W�•�t�,�,�'>f-,'`nLy s.r�' '. -y�^., .-�:y j.. ark .`�=..,. <br /> rCOMMENT_at. 'zvL*Y,.m�L��,l�r <br /> .. :: x�",-n;'h'e�°` t... <br /> THIRD PARTY BILLING INFORMATION: Complete If Billing Party is different from Business Owner identified above. <br /> .................................................."....".........».............................................._............._.......................».................................----.............---............»...........»...............................................---......... <br /> BUSINESS NAME Lf.UQT-A, id U(F_ 5-rn /J Attention�o�rCare Of (optional) <br /> l Ila <br /> T,4 6-1 <br /> Mailing Address <br /> PHONE W- T ' Q q <br /> 5 -Z60q <br /> CITY STAEZIPS76-eTi /S71-67i <br /> ACCOUNTADDRFS for fees and charges OWNER FACILITY/BUSINESS THIRD PARTY BILLING <br /> BILLING AND COMPLIANCE AC"OWLEDGMENT: I acknowledge that all <br /> PERMIT FEET.PENALTIES,ENFORCEMENTCHARGE3 and/or HOURLYCFLIRGES associated with this operation will be billed to me at the address identified above as 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 FEDERAL Laws and Regulations <br /> a I hereby authorize the release of any and all results and environmental assessment information to SAN JOAQUIN COUNTY ENVIRONNNIENTAL <br /> HEALTH DIVISION as soon as it is available and at the same time it is provided to me or my representative. <br /> PLEASE PRINT <br /> APPLICANT NAME PPO\J A- Gj(,kN T SIGNATURE � <br /> TITLE �7"V�(�( �(— (��� DRIVER'S LICENSE# <br /> i <br /> . �..... za•.0 •���....•--srso-stigcty�at�^:�xwc>�,vcrr wex. <br /> Appi~oved Bya v Dafe�k�i�", Accounting Office Processing Completed Date'+' <br />