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San Ina "u Cuue ty i JEtC.) ff Bl ti Serst ces i`nv oflm IVIS40 <br /> `m <br /> DATE I1 �; C� MASTER FILE RECORD INFORMATION FORM (EH0015(REv,$EooSHiM7) <br /> Seaam.a[u ra.END HE Date fIMNE&tD1F GA9E# UNIT IV <br /> OWNER FILE <br /> APLETE THE FOLLOW/NG BUSINESS OWNER INFORMATION: CHECKIF OWNER CuRREMcrONFILEwiTREHO <br /> ................................... <br /> ............................. <br /> ................................ <br /> .... <br /> _................... <br /> ,.......................................................................................... <br /> _....................... <br /> ........... <br /> __.................. <br /> _.................. <br /> _... <br /> . <br /> BUSINESS PHONE <br /> OWNER NAME ______!L-__________r____J______'_v___________; <br /> tut MI Last <br /> BUSINESS NAME(If dh7brent from Owner Name) i SOC SECT TAX ID# <br /> OWNER HOME ADDRESS �Q1 E Mwt(` AVE N JC i DRIVER'S LICENSEcit # <br /> Y C.y.r, STATE C.A i LP gSpZ 0,;L, <br /> OWNER MAIUNG ADDRESS (if01FFERENTfrom OwrrerAddress) Attention:or Care of (optional) <br /> �• o • Sox 1110 <br /> Mailing Address City S-TD U�1"o PJ ! State A `: Zip �j)fa0 <br /> /' 1 <br /> ='=-ro INDIVIDUAL❑ PARTNERSHIP❑ LOCALAGENCY❑ COUNTYAGENCY❑ STATEAGENOY❑ FED AGENCY OTHER 11 <br /> FACILITY FILE <br /> FACR,tTYID# :': CRD58REEIQ# ' - AlCCD3JNT3Q. :f <br /> COMPLETE THEFOLLOW/NG BUSINESS / FACILITY / SITE INFORMATION: <br /> Is this a NEW B49iness LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DIVISION? YES @) NO ❑ <br /> Is this an EXISTING Business LOCATION beta NEW TYPE of regulated Business 7 YES ❑ NO® <br /> BUSINEss/FACIUTY/SITE NAME <br /> OGRESS 1 , � SUITE# i BUSINESS PHONE <br /> 00-t-n <br /> Clrr I V UL� 1 SrnzE� ; LP Sa O-a, <br /> Mailing Address ifD/FFERENTfrom Facility Address Attention:or Care Of(optional) <br /> Mailing Address City STATE ZJP <br /> SIC CDi78 APN'1F � s .< f.'SixaaEM« <br /> THIRD PARTY BILLING INFORMATION Complete if Billing Party is different from Business Owner identified above. <br /> ............................................................._._........................._......................................._...................................................................................._................................I............................._.........., <br /> Care Of <br /> BUSINESS NAMEC b N.b 61Z �Rfi 4 ��}1 No 1,0 61£S r NL, i AtlentiM I Cell V (opb �� <br /> Mailing Addrees 186 ,�� I,I ,.ST ClC.Le , CU 11� T E PHONE �M3q —0518 <br /> CITY S�Cr"tbf) lY J J— STA'f�f ZIP L?Sa O�e <br /> ACCoUNTADDRFSS for fees and charges OWNER FAciuTY/BUSINESS <,:-THIRD'PAfirf Bleu <br /> 31LLING AND COMPLUHCE ACR6OWLEDCMLNfT: 1,the undersigned Applicant,certify that 1 am the Owner,Op aoor,or AMthori;cd Agent of this Business,and I acknowledge that all <br /> -ERMIT FEES, PEVALTTES, EVFORCFffi w CR.utGES and/or MoURLY CRARr s associated with this operation will be billed to me at the address identified above as the ACCODNT <br /> IDDRESS 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 /> tpplicable SNi JOAQULN COUNTY Ordinance Codes and/or Standards and STATE and/or FEDERAL Laws and Regulations. As the undersigned owner,operator,or agent ofthe property <br /> mcated at the above facility/site address, I hereby authorize the release or any and all results and environmental assessment information to SAM JOAQUIN COUNTY <br /> iNVIRONMENTAL HEALi-H DIVISION as soon as it is available and at the same time it is provided to me or my representative <br /> PLEASE PRINT <br /> ASICANTNAME M(C�SL SIGNATURE <br /> URIVER'SLC1E,#1TITLE (PHnToCOPYIRE <br /> Approved By Data Acoourtirsg Office processing Compfeted <br />