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II .................. ... Say ,taa '� Gau2y r� ti� hfeaith Services �� anrrle� : a� H�a1t �i�tl�rr . FORM tEH 0O 15)REVISED 06/11 )97) DATE MASTER FILE RECORD INFORMATION SHADED Aar we rox EHO USE 0my E'¥1NNE&. i0# ' �# UNIT IV OWNER FILE COMPLETE THEFOLLOW/NG BUSINESS OWNER INFORMATION: CREcx Ur OWNER CURRENTLY ON FILE WITH EHD ......................................................................................................... .................. ............................................................................................................................................................................ : BUSINESS PHONE OWNER NAME _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ — _ _ _ — _ _ _ _ — _ _ _ _ _ _ — _ _ _ - - _ _ _ : ........................................................0..........First ......................................_Ml............-...-..--....-.....................Lasl................... ........ .......... BUSINESS NAME (if different from Owner Name) G A SOC SEC / TAX 10 # OWNER HOME ADDRESS TD /Jl �� /� i/ p�-� /r � � r.,r � �1 DRIVER'S IJCENSE47 # T City gyp/. STATE ZIP 9s ,33V OWNER MAILING ADDRESS (ifGIFFERENT from Owner Address) Attention: or Care of (op (onal) Mailing Address City ' stats Zip CORPORATION ❑ HIP- INDIVIDUAL ❑ PARTNERSHIP LOCAL AGENCY C3 COUNTY AGENCY STATE AGENCY FED AGENCY OTHER FACILITY FILE COMPLETE THEFOLLOWlNG BUSINESS / FACILITY / SITE /NFORMAT/ON: Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DIVISION ? YES ❑ NO ❑ IS this an E%ISTING Business LOCATION but a NEW TYPE of regulated Business ? YES ❑ NO ❑ BUSINESS/FACILITY/SITE NAME INC/1� A SITEAOORESS Q )/� I ` 11p YV`• b SUITE # BUSIN SS PHONE CITY ��t0 , STATE ZIP 1 91 ::F 1101110 Ellin f MM Mailing Address if0l/T F"F�E�RENTfrom FacilifyAddress E Attention: or Care Of (optional) Mailing Address City ' STATE ZIP $IG CokTE .-- -:-APN#- : COMMENT, THIRD PARTY BILLING INFORMATION: Complete if Billing Party is different �from Business Owner ldentir/edabove. .................................................................1...........................................--..--......--..........................................................-.--.--.-...--..........................................................................--............................-, BUSINESS NAME / �A-L //„ r� _ . ! Attention: or Care Of (optional) Mailing AddressyJ •7 PHONE CITY T\ ((1�/)(( 7 J STATE ! STATE/TZJP 9CCouNTAOoaEss for fees and charges OWNER FACILfN/BUSINESS THIRD PARTY BILLINGI`(,' BTLcmG , D COM1IPLrAHCE ACIOVOWLEDG1 6 I, the undersigned Applicant, certify that I an the Owner, Operator, ordudsorizedAgemt of this Business, and I acknowledge that all PEMHT FEES, PEN.ILTTES, ENFORCEDIENT CHARGES and/or HOURLY CEARGES associated with this operation will be billed to me at the address identified above as the Accqu T 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 applicable SAN UOAQum COUNTY 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 DIVISION as soon as it is available and at the same time it is provided to me or my representative. PLEASE PRINT - APPLICANT NAME SIGNATURE TITLE DRIVER'S LICENSE # raHnrnnoov RFnnlRFn1 Apprtves! Hy _-:HateZ/ 'T Aoaount£tTg Ci£ACe £roaessing C"umpleted 9Y 6ata A{ t