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bb <br /> MASTER <br /> STER�FILEEr RECORD INFORIii3AMR555A''TION�"'MFR"' <br /> DATE Atmm" �fO-:wf�tytM <br /> *. <br /> sassum-----M�T — 3 2006 ° <br /> UNIT IV <br /> ENVIPIONMENT OWNER FILE <br /> COMPLETET <br /> CKTY OWNER INFORMATION; CNECKIF OWNER NRRExnronFJeE wrrHEHD ❑ <br /> PROPERTY OWNER PHONE <br /> NAME ✓` \ — t 'N.�vI-% <br /> First MI last <br /> BUSINEss NAME Soc SEc/TAX ID# <br /> Owner Home Address _ DRIYER's LICENSE# <br /> l�a1Sv V I NL _ <br /> city -C2 Rte; STATE Ga zm 3 <br /> owlw Mailing Address 1 CI'��� 1 ymi <br /> Mailing Address City -�� ` state( LP OI' 3 7 <br /> Ivor nu nwxcvcury <br /> fnoonsrbnnx❑ Txrurrou ❑ PAsvwncom Fun arcxrv❑ (1TlaR❑ <br /> IEL A <br /> Is this a New Business LouTioN not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? Yes ❑ No ❑ <br /> is this an EximmG Business LOCATION but a New TYPE of regulated Business? YES ❑ No ❑ <br /> BUSINESS/FAQLITr/SM NAME <br /> YY1JS �' rYarn\l�� � L t!F CJ <br /> SITE ADDRESS SUITE# BUSINESS PHONE L� <br /> --75-t) yIK1 NiC-Z-,UOcm � 7` l -X3J— fWC7 <br /> STATE zip <br /> c � q �3 7 <br /> Mailing Address KDIFFERENTlhom fad/ityAddfes; Attention:or Care Of(optional) <br /> Mailing Address City STATE zip <br /> THIRD PARTY BILLING INFO: Complete if Billing Party is different from Property Owner or Facility Operator identified above. <br /> BuslNess NAME Attention:orCare Of (optional) <br /> � clS <br /> Mailing Address PHONE r, <br /> v y1119 n�lc_ "�� � � �-536 `_c <br /> cm STATE ZIP <br /> Accauffr AaaRfss for fees and charges OWNER FACILITY/BLJSINE-S THIRD PARTY BILLING <br /> R C 1 nxrr ArRNnwt cnr.MF W: I,the undersigned Applican4 certify that 1 am the Owner,Operatoq or Authorized Agent of this Business,and I acknowledge that all PERIOT FEES, <br /> P£NALrfFS,ENFORCEMENTCIIARGES and/or ROUrt YCHA GES associated with this operation will be billed to mat the address identified above as the accatt T ADDRFsy 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 facilitylsite 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 /> PLEASE PRINT <br /> APPLICANT NAME SIGNATURE/ <br /> TITLE DRIVER'S LICENSE# <br /> (PHOTOCOPY REOulnED1 <br /> yed By; ,„j . :=f,-, n9 PlocesSmgSoldPlebed,By`,a. fat? " ^F' .'.. <br />