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_ l7K[cl'{ rvrtrr DATE MASTER'FILE RECORD INFORMATION MFR" ,yy UNIT IV OWNER FILE CrrEGYCIF OWNER CuaRENrxroNFzcFwrnrEHD ❑ COMPLETE THE FOLLOWING PROPERTY OWNER' 770N.' PROPERTY OWNER PHONE NAME a2S (,,2.(v 2 First MI last BUSINESS NAME SOC SEC/TAx ID# Owner Home Address l LYS rZ-L DRIVER'S LICENSE# city STATE ZIP owner Mailing Address State Mailing Address City zip -)-C)L� l Ltd C TYPE nF nMMERCNTP f noonoennu❑ Tunn crams❑ PeotwFR.TPJEAr,111 Int Fill F-❑ FFn AcFury❑ rtn+FR❑ 5c) t_ ACII ITY TD I txu0'fr a P SITE MfQHM7-r0N; s is this a NEW Business LocanoN not previously regulated by the ENvntoNMENTAL HEALTH DEPARTMENT? YES No ❑ Is this an Exls TNG Business LOCATION but a NEW TYPE of regulated Business? 0) 2 248 YES ❑ No ❑ BUSINESS/FACILITY/$ITE NAME — L_+ E N VI R V N M t-N G T i 1 F .I A i` Bt15INESS PHONE SITE ADDRESS STATE ZIP CITY " & I10mgm ... Ju�+_5 .._t from Faci/ityAddrless Attention:or Care Of(optional) Mailing Address if DIFFERENT 16 Mailing Address City / STATE ZIP q /.S ZNAMy % THIRD PARTY BILLING INFO: Complete if Billing Party is different from Property Owner or Facility Operator identified above. Attention:or Care of (optional) BUSINESS NAME PHONE Mailing Address STATE CITY ` Z uP Q S �- At'MffAT ADDgEss for fees and charges OWNER FACILITY/BUSINESS THIRD PARTY BILLING Rif t INC ANO(nnter tnxr> Art xawl cnCntENT: 1,the undersigned Applicant certify that I am the owner,Operator,or Authorized Agent of this Business,and I acknowledge that all PExsfrT FEES, PENALTIES,ENFORCEMENT CH.IRGES and/or HOURLYCHARGES associated with this operation will be billed to me at the address identified above as the Arrnrm rADDZ&Li 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 Cou?,"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 DEPARTMENT as n as it is available and at the same time it is provided to me or my representative. / PLEASE PRINT APPLICANT NAME l �� " 7{� � L�4 � j "C- SIGNATURE T DRIVER'S LICENSE# �iZzr`! t� �t� \ (PHOTOCOPYREOUIRED) -Z- TITLE .wz.�, xarsere^�1 4 3.Y+.,Itflw35"T.