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. <br /> S Jaai o :1 un tI >"fieei Zre> rtes: Env ren t 1 H a1�t � � t <br /> DATE MASTER FILE RECORD INFORMATION FORM (EH 0015(Rt:wsl:D O6H1197} <br /> ;: <br /> UNIT IV <br /> SHADE AREA!FON D U 0-V - - <br /> h i ....._. ........... ..YMER .......: ....: :: <br /> �``�a ► � o �wOWNER FILE . <br /> COMPLLT *1"fE'�VL16WIkG USINESS OWNER INFORMATION: CHECKIF OWNER CURRENTLYONF/LEW/THEHO <br /> ... <br /> .............;............................................................................... <br /> ............ <br /> BUSINESS i YI �—�y��.�^ PHONE <br /> �q�J-�lf'i�j/ �3,1/vs_,Sr(L ../ �1/T =JT 11 l�.l ✓ i <br /> ......OWNERME.... . I. �I I�`/rl�.l.R:>.v..LPi� rr..M.l.`........ ... ..Q..f�F�-�-.L�.I #.............. <br /> BUSINESS-N"Y jif ) SOC SEC/TAX ID# <br /> OWNER HOME ADDRESS 305' ,ryt/ i/ µ. /� \ \/- DRIVER'S LICENSEcit <br /> Y OB VT C��.I Itl�ri�✓V ei �t� STATECA ZIP'35-403 5-403 <br /> OWNER MAILING ADDRESS (if DIFFERENT from Owner Address) Attention:or Care of (optional) <br /> Mailing Address City ` State Zjp <br /> Ty w IN <br /> CORPORATION❑ INDIVIDUAL❑ PARTNERSHIP❑ LOCAL AGENCY❑ COUNTY AGENCY❑ STATE AGENCY❑ FED AGENCY OTHER❑ <br /> FACILITY FILE N1 0 <br /> COMPLETETHEFOLLOW/NG BUSINESS / FACILITY/SITE INFORMATION: <br /> Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DIVISION? YES ❑ NO <br /> Is this an EXISTING Business LOCATION but a NEW TYPE of/regulated <br /> Busiinesss? ` YES NO ❑ <br /> BUSINESS/FACILITY/SITE NAME <br /> _1 i( Ar) <br /> moi{ -�/' Q,,�/ '� ✓� <br /> SITE ADDRESS ✓ r-+ F\u Gti� tJ SUITE# � SINE�;PHO E <br /> CITY <br /> STAT <br /> Zi <br /> o eA . sZV3 �� zo <br /> Mailing Address ifDIFFERENTfrom Facility Address Attention:or Care Of(optional) <br /> Mailing Address City STATE ZIP <br /> ... <br /> SIC GcyD€ AP3il# E <br /> THIRD PARTY BILLING INFORMATION: Complete if Billing Party is different from Business Owner Identified above. <br /> ............'............................................................................................................................................................................................................................................••-------...................................---- <br /> BUSINESS NAME Attention:or Care Of (optional) <br /> Mailing Address E PHONE <br /> CITY STATE ZIP <br /> AcCQU11/TAD0RE5$ for fees and charges OWNER FACILITY/BUSINESS THIRD PARTY BILLING <br /> BILLPINC AND COMPLIANCE ACKNOWLEDGMENT: I,the undersigned Applicant,certify that I am the Owner. Operator,or Authorized Agent of this Business,and I acknowledge that all <br /> PER511T FEES, PEIVAL=. E.VFORCEVENT CHARGES and/or HOURLY CHARGES associated with this operation will be billed to me at the address identified above as the ACCOUNT <br /> IDDRFS.S 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 <br /> applicable SAN JOAQULN COUNTY Ordinance Codes and/or Standards and STATE and/or FEDERAL Laws and Regulations. As the undersigned owner,operator,or agent of the property <br /> located at the above facility/site address, I hereby authorize the release of any and all results and environmental assessment information to S4N .JOAQUIN COUNTY <br /> ENVIRONMENTAL 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 J]OW G. VIlRKERK SIGNATURE <br /> TITLE CZCM IN CHARM DRIVER'S LICE SE# N/A <br /> 1 <br /> {lRpPoved: Da#e: kattt►ist3ng t#flaesaae§stng Gariieter# 3att n' <br />