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09-21-1999 04: 12PM FROM TO 19258387425 P.02 :m v �: :i: :ii :a:3:•d % 3iSS '� �°f .k x^.i.'.;::<;.<:e': r :ak,: ... .,. x• ��', � :�� "�". ..�' ��i� 'Q p;',fox :i':::n%xur:::r, .•ate .rte/..'^'........t.....,,..fv ..w.....,. n�......�J.. a„.w�.,.. � � .. x. >b, zx DATE MASTER FILE RECORD INFORMATION FORM (EH 0015(RE 8r.D 0QM 1197) ahwnMAK. row HO ata Oe r p� ,.: �.:. .e UNIT IV OWNER FILE COMPLETE THE FOLLOWING BUSINESS OWNER INFORMATION_ CMECKIF OWNER CURRElV7LY6NFI4LCwITHEHO 0 - ---------...................—..................,...............:........-..----•---------- ...............................--......................................—.................... —-------•—._.............................................. BUSINESS i PHONE .OWNER NAME '------------.--»---=---------- ---------- ----- (q25) X66.122 .....-•----••-----------•------ t---------------------............... 2 BUSINESS NAME(tf dlfTersnt fi VW OWner Nam*) SOC SEC1 TAX ID s RYLAun I-toKf OWNER HOME AOORESS '; DRIVER'S LICENSE 8 NIR ChY STATE Zip OWNER MAIUNG ADDRESS (rf01FFEREN7'f-om 0wr rAdrtresa) Attention;or Cam of (gpglorW) ��Gy7 Atc6STil BL1VA SU17F /90 0006 kAZA/PL-NO.S Mailing Address City SA N RaA oyStt ��} Zip itis Q3 9 FCORPORATION_X INDIVIDUAL 0 PARTNERSHIP 13 LOCALAr.ENC1i 0 COUNTY AGENCY 0 STATE AGENCY 0 FED AGENCY 0 OTHER 0 FACILITY FILE k COMPLETETHEFOLLOW/NG BUSINESS/FACILITY/SITE INFORMATION; Is this a NEW Business LOCATION riot pr*ViOU*Iy r*gtuWbed by the ENVIRONMENTAL HEAI.YH OIW9ION? uta ea4owH Yes ■ No 0 Is this an easT1NC Business LOCATION but NEW TYPE of regulated Business? tt K/(uOW1, YES IN No O BUSINEss/FACiuTY/SITE NAME RYLA,u» SUruC7cOA) / ZRACYES,,,_7RTES SITE ADDRESS SUITE# BUSINESS PHONE Ltoo S. TRNar/ 16L Via ,JIB crrr 7)?4 CX ZJP ”?5 3V 00,11 x k f,kH: .S .�J(. O ':b Maeivc«•X Mailing Address/f0/FFERENTfrom FacdilyAddr3ss Attention_or Care Of(optional) ,VIA Mailing Address City STATE ? LP Y• � .k .y / k a� « THIRD PARTY BILLING INFORMATION: Complete if Billing Party is different from Business Owner Identified above. ..........................-...................... --------------------..... -- --- - - _....,........................................................................................................... BUSINESS NAME FN6E0 .T�tacbnPorti4?E Attention:or Caro Of (Opm(ara) b k57S. cxiz b Mailing Address Z YO I C'f o 4) CAA�Y4/U ROA/� Su!7F. X00 PHONE CITY s'^ KPl h w VOaP 94 Q 5 O dgpA%ZN7'ADnRE.g for fees and charges OWNER FAcum/BuslNEss CIHIRD PAFM BLU BILL,00 AND COMPLIANCtt 4,Ct0OVyM,ISOCMtTv7: 1.the undersigped Applicant,certify that I am the Own®a Operdxor,or,4uA0ri:ed Awns of this Business,and I acknowledge that all PERMIT Fe&, PENA17fES, ENFORCEMENT CMAOZS aadlor HOURLY CHARGES associated with this operation will be billed to me at the addrvss identified above as the ACCO[/Nr ,Inns Ss 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 acc-ordarnce with all 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 located it 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 a.whible and at the same time it is provided to me or my representative _A/ PLEAsr PRINT APPLICANT NAME �NC � C� SIGNATt1itE TITLE DRIV LICENSE s �je/�y c i p� lorxrrer_�Pv a a ttaFel /IIA :x +••r:n„X:x.�aw,.«X-X�.o so ex«.,�k.,, oxXr� �hw. ay ip. V RI:CQt L�.Lr6i6rjJ � :.,.. ....... ....: .n:..%M:...el..�`..Z•1,... � ...... .. '. � M �< 'Tau;d: i! ''.i>?"f^«x�'�',� k 5'i