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ra o i ak'�� �'�! �i '� .� � � vkn>"+v ' �,^a• � K��'t '� q"�F. r 's•�''.�:F��t�+�,�v,.� ,�� � �,`jl r x�a:i � SSR+ae t•.� � r +,�v .,.� ,i <br /> URttN I <br /> DATE MASTER FILE RECORD INFORMATION "MM" <br /> UNIT IV <br /> CASE <br /> OWNER FILE <br /> CHECK IF OWNER CURRENTLY ON FILE WITH EHD ❑ <br /> COMPLETETHEFOLLOWINGPROPERTY OWNER INFORMATION; <br /> PHONE <br /> PROPERTY OWNER ///r' n Q '7 <br /> NAME �' PJ Cow, <br /> w, 6J ( / S 3 <br /> First MI last <br /> _ SOC SEC/TAX ID# ( c <br /> BUSINESS NAME 1 I L 1 4: <br /> Owner Home Address A DRIVER'S LICENSE# <br /> 0 196 <br /> City ter--, STATE <br /> le <br /> owner Mailing Address <br /> State Zip <br /> Mailing Address City <br /> TYRF of mulswi CHm <br /> FFD Ar_FNN❑ r)T{IFD <br /> rllRDlIR OTrr1N TNr1MM1E1 ❑ DODTJFOCHiR❑ <br /> FAIIIIIIII 13X Ell IF <br /> u � d" INY# <br /> FACILITY ID#" CRossRE�ID'#, 1 g ACcouNTID#; .„ r. <br /> MPLETE THE F LL WIN NF RMATI N' <br /> Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES Ki No ❑ <br /> Is this an E)aSTING Business LOCATION but a NEW TYPE of regulated Business? YES ❑ No ❑ <br /> BUSINESS/FACILmiSrrE NAME <br /> � C� � �G E�C4 V Q!/I1 i/7 C��1 r T 1/ .1 it 1• � --LTJ ��,c <br /> ,Q SUITE# BUSINESS PHONE <br /> SITE ADDRESS <br /> 17 7 ) 5i� /16 J09- 7,2 7- 563 <br /> O STATE ZIP <br /> Cm J / •� <br /> OAO <br /> Mailing Address ifDIFFERENTh0mFaci/1tyAdd1e" Attention:or Care Of(optional) <br /> Mailing Address City STATE ZIP <br /> THIRD PARTY BILLING INFO: Complete if Billing Party is differentfrom Property Owner or Facility Operator identified above. <br /> BUSINESS NAME Attention:ot-Care Of (optional) <br /> Mailing Address PHONE <br /> Cm �^ STATE zip /-)72 3 <br /> dWr^r LW1 dDD9E S for fees and charges OWNER FACILITY/BUSINESS THIRD PARTY BILLING <br /> Rn t INC AND COntrt t+NCE ACKNOWT FDGMFNT: I,the undersigned Applicant,certify that 1 am the Owner,Operator,or Authorized Agent of this Business,and I acknowledge that all PER511T FEES, <br /> PENALTiEs,ENFORCEMENT CHARGES and/or HOURLYCIIARGES associated with this operation will be billed to me at the address identified above as the ACCnr,vTAnnxF.c.c for this site. 1 also certify that all <br /> information provided on this application is true and correct;and that all regulated activities will be performed in accordance with all applicable SAN JOAQUIN COUNTY Ordinance Codes and/or <br /> 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 <br /> any and all results and environmental assessment information to SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my representative. _ / <br /> uP�� SIGNATUREVdl / <br /> APPLICANT NAME <br /> TITLE ` /^ /1 .II r d F _ PRIVER'S LICENSE HOTOCOPY REQUIRED# <br /> ..... .. .. ... <br /> Approved By Date Accounting Office Processing Completed By .Date <br />