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Sam Jaa > QuL3l::.. ,3�tct Sere# e ::...£tu ot>i» E- eihon::.... <br /> DATE MASTER FILE RECORD INFORMATION FORM (EH001S(REVI3E00611119T) <br /> ee0air <br /> SHAD D Aarws FOR EHD u " ` """"'" UNIT I V <br /> 4�YVKQEfi'?1�1ii:% ;; _ _ E�iASE <br /> OWNER FILE <br /> COMPLETE THEFOLLOWING BUSINESS OWNER INFORMATION: CHECK/F OWNER CURRENTGYONF/LEW/THEHD <br /> ............................................................................................................................ <br /> BUSINESS PHONE <br /> OWNER NAME ------------------ -- ----- ———— <br /> ...................................................................First....................................... ...............................................Last......................................: <br /> BUSINESS NAME(If different from Owner Name) i SOC SEC I TAx ID# <br /> OWNER HOME ADDRESS DRIVER'S LICENSE# <br /> y STATE ZIP <br /> Ck <br /> OWNER MAILING ADDRESS (ifDIFFERENTfrom Owner Address) E Attention:or Care of (optional) <br /> Mailing Address City State Zip <br /> CORPORATION 11INDIVIDUAL❑ PARTNERSHIP❑ LOCAL AGENCY❑ COUNTY AGENCY C3STATE AGENCY❑ FED AGENCY❑ OTHER❑ <br /> FACILITY FILE <br /> 77 <br /> COMPLETE THE FOLLOWING BUSINESS / FACILITY I 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 Business? YES ❑ NO ❑ <br /> BUSINESs/FACILITY/SITE NAME <br /> SUITE# BUSINESS PHONE <br /> SITE ADDRESS <br /> STATE ZIP <br /> CITY <br /> Mailing Address dDIFFERENTfrom Facility Address E Attention:or Care Of(opt/ona/) <br /> STATE ZIP <br /> Mailing Address City <br /> ? -` <: <br /> . E <br /> �I <br /> C . <br /> THIRD PARTY BILLING INFORMATION: Complete if Billing Party is different from Business Owner ldendf/ed above. <br /> .................................................................................... ... <br /> BUSINESS NAME Attention:or Care Of (optional) <br /> PHONE <br /> Mailing Address <br /> STATE ZIP <br /> CITY <br /> _q�rnr/NTADORESS for fees and charges OWNER FACILITY/BUSINESS THIRD PARTY BILLING <br /> BILLINC..aND CoMPL1.LNCE ACEC40%-LEDCMENT: I,the undersigned applicant,certify that I am the Owner.Operator,or Authorized Agent of this Business,and I admowledge that all <br /> PER.11lT FEES, PEN.tLTlES. ENFORCESIENT CHARGES and/or HOURLY CHARGES associated with this operation will be billed to me at the address identified above as the ACCOlL'VT <br /> ADDRESS 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 JOAQUIN 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 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 SIGNATURE <br /> DRIVER'S LICENSE# <br /> TITLE 1PH^ RFn1 <br /> APProvted 8y Qaig Accounting OfffcrPioeessing Ca npfeted.8y..;., > ............................ <br />