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... <br /> Count tiUC ............ Ec� osxaaE HeaitEt Eaivision <br /> FORM (EH0015(REVISEo0811119Tj <br /> DATE I� � D� MASTER FILE RECORD INFORMATION <br /> y W UNIT IV <br /> Sxxoeonxrwerox ENO uar Oxirt�/ffE` TI _:': FJJKws ;:�A$� ."' A <br /> OWNER FILE <br /> COMPLETE THEFOLLOW/NG BUSINESS OWNER INFORMATION.- CNECKIF OWNER CURRevrcron File WiTHEHD <br /> ......................................................................................................-............................._......................................... <br /> BUSINESS i Or 5� .I-a� NE <br /> OWNER NAME ____�_L'_ _________r_______________________F PHO <br /> .................................................................._ER!.......................................M!...............................................L@F.l............._.......................: <br /> BUSINESS NAME(if diRerentfrom Ovmer Name) ' ,1 � 4(1 /' E SOCSEC/TAXID# <br /> OWNER HOME ADDRESS �QI E r MINc.F] AVIEA)v ! DRIVER'S LICENSE# <br /> city S-P l„ \ <br /> STATE i LP �SpZ0� <br /> OWNER MAILING ADDRESS (ifDIFFERENTfrom OWrrer Address) f Attention:orCare of (optional) <br /> F n Box Ilio <br /> Mailing Address City S�uL�� ` Stam CA ' Zip 1500 I <br /> CORPORATIO 1 INDIVIDUAL 13 PARTNERSHIP 11 LOCAL AGENCY COUNTYAGENCY❑ STATE AGENCY 13 FED AGENCY OTHER <br /> FACILITY FILE <br /> FkeL#T1 F#3 f{...�` ���:: � .S`Ros3.RE1✓ID#:: ...eceoUN7 t€}A- �'�: ��- :< f - ��� <br /> COMPLETE THE FOL LOWING BUSINESS I FACILITY I SITE INFORMATION. <br /> Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DIVISION? YES'All NO ❑ <br /> Is this an EXISTING Business LOCATION but NEW TYPE of regulated Business? YES ❑ No <br /> BUSINESSIfACIDTY/SITE NAME �oSG����L <br /> SITE ADDRESS ��# BUSINESS PHONE <br /> CITY STp LlLfib tJ S ! srnTEd ZIP <br /> Mailing Address it'D/FFERENTfrom Facil/fyAddress i Attention:or Care Of(optional) <br /> Mailing Address City ' STATE ` Zip <br /> SIC cam: APN# r'iDMMEl <br /> THIRD PARTY BILLING INFORMATION: Complete if Billing.Party is different from Business Owner Idenbfted above. <br /> ......................................................................................................................................... ...............................___•..............................._............................................................................ <br /> BUSINESS NAME _TNL. AllantIZ1 0 (MC(ZI(/e <br /> CON96r- �Rtl4 ���}INoLohl£ <br /> PHONE AddressSU 7� a3y _658'VUUCI gC1- <br /> CITY STE LP �Sa <br /> o 6S V CV"�,V <br /> qcroumEAOORES3 for fees and charges OWNER FAauTYIBUSINESs - THIRvPaFiTr Biud <br /> BILLDVG.WD COMPLLWCE ACICAOWLEDGMENT: I,the undersigned Applicant,certify that I am the Owner,Opermor.or duthomeddgera of this Business.and I acknowledge that all <br /> PERMIT FEES, PENALTIES, ENFORCEMENT CHARGES and/or ROURLY CHARGES associated with this operation will be billed to me at the address identified above as the.accolM. <br /> ADDRESS for this site. 1 also certify that all information provided on this application is true and torten; and that all regulated activities will be performed in accordance with all <br /> applicable SAN JOAQUIN CoIJNTY 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 or am, and all results and environmental assessment information to SAN 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 M(L"-E{ L �( ( — - SI 'NATUR 1111////,f�VV'fffVVV//L <br /> TITLE •�NU I DRIVER'S LICENSE# 3 <br /> Rc,N l✓ InunT <br /> i ft L i ST rlr.nur RP-1itcFr, <br /> AITIa1bV tl <br /> TA <br /> BY Dat Accodilng Office F'roeessing.Conlateted gy ay �Z `: <br />