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<br /> As—rFR FILE RECORD INFORMATION fpR'" fpHppls(Rtvtaeo0tl/tt1911
<br /> DATE _+, _ _
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<br /> OWNER FILE
<br /> COMPLETE THEFOLLUW/NG
<br /> CHECK/f.OWNER Cuifte friroNFILE wrHEND
<br /> L3USINESSOWNER /NFORMA77UN::....:...................................... ....:..............................................:.....................I.......................}
<br /> BUSINESS % �7`�"(�R i ��f� PILON may! —
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<br /> OWNER NAME ,
<br /> .......�r!tt................... to __._....LAa<f..._._........ I
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<br /> BUa1NCas NAME(H d#Ferent I'fvm Ow)or Nang) f� % Soc 5Ec I TAx IU ad
<br /> OWNER NOME ADDRESS % DRIVER'S UCEN5E K A(36 tlo.F J
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<br /> City
<br /> $TATfry�,_. ZIP
<br /> OWNER MAILING ADDRESS (ifO/FFERENTIironr OwnarAddrd",i Attontiun:or Care of (opOoti&1)
<br /> Mailing Address City .r6 r r J r n/6S✓ �ls�/ �79d�y M StAta ZIP 9 5'F,4.
<br /> CORPORATION❑ (NptVIpUA1 PARYN9ASHIP❑ LocAL AGENCY❑ COUNTY AGENCY❑ STATE AGENCY❑ FED AGENCY❑ OTMER D
<br /> FACILITY FILE
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<br /> COMPL,cTETME!"OLLOW/NG BUSINESS/ FACILITY / SITE INFORMATION:
<br /> 13 this a NEW gu.ainer"LOCATION not Previously r*gulateti by tht ENVIRONMENTAL HEALTH DIVISION I YES NO ❑
<br /> Is this an EXI;TINA Business LOCATION but a NEw TYPE of regulated Business 7 YES NO N _
<br /> BUSINESSIFAGILITYISITE NAME
<br /> SITE ADORESSSUITE# BUSINESS PHONE
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<br /> CITY $TAT zip l
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<br /> Mailing Address d'DIFFERENThnm FacillfyAddrtlss i AdtAtlott:or Care Of(optional)
<br /> Mailing Address City ���- ? SYATV i ZIP
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<br /> THIRD PARTY BILLING INFORMATION: COmpiete if Billing Party /a diff crent from tsuslness.owner Identified-above.
<br /> ...................................................................
<br /> BuswEs9 NAME i Attontlon: or Care Of (optional)
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<br /> Mailing Addrei PlipNfi^
<br /> ss
<br /> CITY SYATEZ
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<br /> g OflNl. 9R�?lj rs for fees and charges OWNER FACILITY/BUSINESS THIRD PARTY BLUNG
<br /> un s rNr rvn f nMpl leWi') ��1CNOtVLEiIr11ENTI 1,the underslgntd A,pplicanl,certify that I Ken the Owru �v,Operator,or, whoriyed Agertr of thlt Busintm,and I aclmowled;e that all
<br /> pgxs/tr FFRS. 1'F;vaGTIB•v, _FXT0ACPAMNT CH.4,9e ;S stud/or MouriQ CmAnGLs associated with this operhtion will lac billed w me At the address identified alcove as the ,seem
<br /> nn for This site. I also certify that all information provided on this application is true and correct; and that all regulattd adivitica will be performed in accordance with .11
<br /> apptleahh:SAN JOAQUW COUNTY Ordinance Codes and/or Standard-anJ SYAT1f and/pr FtpeRA1.Laws and Regulations. As the undersigned uwnur,operator,or ngent of the pmperty
<br /> located at the aboVe I'acillty/-ilk Addresi, I hereby authorize the release of any and all results and environmental assessment inf n to SAN JQjQLr NT
<br /> ENS"iJtt>NDII;NTAL HEALTH DIVISION as soon as it is availahle and ut the same time it is pro-idcd to me or my reprementativa. /
<br /> tq7V,D' +`'n�• ' ,�_, SW PLEASE PRINT ,
<br /> APPLICANT NAME SIGNATURE
<br /> �, DRIVER'S LIC H a ,f /�` y D
<br /> TITLE 0GJ/�t�i� SQZQrAPV RCAi11RF�� Y
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