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_SMMUo 1 0 WiRgrealit <br /> ,i,eal_tEif,Di_vlslon ' <br /> r DATE MASTER FILE RECORD INFORMATION FORM [EH 0015(REvsFD07123f97) <br /> ;;NADED AREAS FOR CHD,y QHL1' O�'HNERsID UNIT IV <br /> OWNER FILE <br /> COMPLETETHE FOL L0WING 6USINESS OWNER INFORMATION: CHEcxlF OWNER CURRENTLYONFILEWITHEHD <br /> ---------_......... ..._......... <br /> BUSINESS ^o <br /> K i �/J' PHONE <br /> OWNER NAME — ------- ---�-- <br /> ..........................................................._.F.rzt................._...._-_...____.M._ ------------------- <br /> ...._.__...... .».._.__.....Calf....__-.............................. <br /> BUSINESS NAME(tf different from Ownerme) SOC SEC/TAx ID# <br /> 'j tX <br /> OWNER HOME ADDRESS <br /> DRIVER'S LICENSE# <br /> ' crtY G770)GjK_7V7k) I <br /> STATE ZIP �S ��y C� <br /> OWNER MAILING ADDRESS (if DIFFERENT from Owner Address) ; Attention: or Care of (optional) <br /> fJ <br /> i <br /> '.; Mailing Address City State Zip <br /> CORPORATION 2-1, INDIVIDUAL❑ PARTNERSHIP❑ LOCAL AGENCY❑ COUNTY AGENCY❑ STATE AGENCY❑ FED AGENCY❑ OTHER❑ <br /> FACILITY FILE <br /> •"COMPLETE THE FOLLOW/NG BUSINESS / FACILITY/ SITE INFORMATION: <br /> Is this a NEw Business LocnnoN not previously regulated by tfie ENVIRONMENTAL HEALTH DrvISION 1 YEs C3 NO <br /> Is this an ExisnNG Business LOCATION but a NEW TYPE of regulated Business 7 <br /> YES� N0� <br /> BUSINESS/FACILI ITE NAME � � �7� <br /> TL AjG <br /> SITE ADDRESS ` �i C ���/ SUITE# BUSINESS PHONE <br /> Viw <br /> CITY �7V ST 6 Zip <br /> ;y "r r�.�i.xk• � <br /> .:i�wryrr ,..''�3'yr ��� z:� cyy������'.':;1".� 'M`'I+''y..'�!.'.ti'�•�.t"`�!Y-�-,"c 9�,I-C'Y6'L f+c 1Yt'�q'�' " ;,Y Y,t,�'1 C. <br /> wv <br /> Mailing Address if DIFFERENT from Facility Address Attention: or Care Of(Optional)t <br /> k� <br /> Mailing Address City <br /> a: ! STATE ? ZIP <br /> s's+u:ik� tY <br /> a SIC'CO i'a�a = i ki4PN: 1�Afi ''a3i •' r �.�. <br /> e-�iYc_ .COMMEM""rxatssmR4�+T+ i:hT4a` '"�1 Nn +='3Twi�* -�u �* ^• <br /> THIRD PARTY BILLING INFORMATION. Complete/f Billing Party /s different from Business Owner IdentJfe <br /> ................................................. dabove: <br /> ........... .. .. ..... <br /> BUSINESS NAME t 1L)Q_FA,L.1 d Fe:U A ; Attentio or Care Of (optional) <br /> � ^ a uNI ,•o <br /> Mailing Address <br /> )4-("- ' PHONE q -Zoo <br /> iCITY <br /> CITY S7 STATE ZIP <br /> 4CCOUNI'1442ESS for fees and charges OWNER FACILITY/BUSINESS THIRD PARTY BILLING <br /> BTLLING AND COMPLIANCE ACKNOWLEDGMENT: <br /> I acknowledge that all <br /> i'PERMrr FEEs,PENALT7ES,ENFORCEMEvr CHARGES and/or HOURLYCIL4RGES associated with this operation will be billed to me at the address identified above as the ACCOUhTADDRES: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 FEDERAL Laws and Regulations. <br /> a . I hereby authorize the release of any and all results 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 to me or my representative <br /> PLEASE PRINT <br /> APPLICANT NAME 7Lk SIGNATURE <br /> F TITLE ATV X1JU;7� DRIVER'S LICENSE# <br /> IPHOTO OPY RFOL11RFDI <br /> g!+PPr°ved ,.,a P Y DateLt ',t" � <br /> >. u FAccalnUng Office Ptrocessi Com Ceted'B �' °" <br />