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a -J Ill . ;00 <br /> St0 <br /> DATE MASTER FILE RECORD iINFORMATII._„- 'Drat tEE►oolr(Rt,+laEuoTna+sy) <br /> (.�v� os /000 <br /> swamkpAaeAa� EHD use OwLr _ UNIT IV <br /> V OWNER FILO <br /> COMPLETE THEFOLLOWING BUSINESS.OWNS INFORMATION.' CHECXIF OWNER CURRENTLYONRLE*nNEHD <br /> ......................__._-._-_...__ __ ._ �.. _..._._.... .__ .. ._ _�...... ._._....-.._..__.- _. —-- -- ----------- ._. _. .... . . . --- <br /> BUSINESS i �A FINE <br /> OWNER NAME �•----- --- ---�I—G—I—/ - ---------- 39rs-� <br /> ....................................�....._.... -----------------..------ --------- ------ - ---- <br /> BustNess NAME(If different from Owner Name) ' Soc SEc f TAx 1 D# <br /> OWNER HOME ADDRESS ` DRIVER'S LICENSE# <br /> City F zp STATE 71P <br /> OWNER MAILING ADDRESS (ifDIFFERENTfrom Owner Address) ; Attention:orCare of (optional) <br /> Mailing Address City State S Zip <br /> TYPE of:n%&Mr0'U4113- <br /> CORPORATION❑ INDIVIDUAL❑ PARTNERSHIP❑ LOCAL AGENCY© C0UNjj AGENCY 0 STATE AGENCY❑ FED AGENCY❑ OTHER❑ <br /> FACILITY FI 'E <br /> FAdI MOM CRoss REr:I t k10. <br /> Comn=mEFOLLowmb BUSINESS 1 FACILITY I SITE INFORMA": ON. <br /> Is this a New Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH(Dlvistom? YES ❑ No <br /> Is this an EXISTING Business LOCATION but a NEW TYPE of regulated Business? YES p ND <br /> BUSiNESSIFACIIJTYISITENAME <br /> ��" _.��r. 1_li�ti i!.'�� LT`L` �� •vii � l �.. <br /> SITE ADDRESS _ t SUITE# BUS ESS PHONE{t6r - V23 <br /> -``Ill <br /> CITYTE LP <br /> Mailing Address ifDIFFEREMrfmmFacility Address Attention:or Care Of(optional) <br /> Mailing Address City STATE ': ZIP <br /> THIRD PARTY BILLING INFORMATION: Complete if Billing Party is different from Business Owner Identified above. <br /> .............. ».... . ................................._....._r......�_ .....................-------.................-.............................. <br /> BUSINEss NAME Attention.orCare Of (optional) <br /> F <br /> Mailing Address ': PHONE <br /> CITY STATE ZIP <br /> AccouNrAvDREss for fees and charges OWNER FACluTYjfBUSiNESS THIRD PARTY BILLING <br /> BILLING AND COMPLIANCE ACKNOWLEDGMENT: L the undersigned Applicant,certify that I am the jOwner,Operator,or Authorized Agtwt of this Business,and I acknowledge that all <br /> PERMfT FEES,PENALn Es,ENFORCEwFNT CAARCE4 and/or HOURLY CHARGE4 associated with this o"tion will be billed to meat the address Identified above as the ACCOUNT ADDRF_44 <br /> for this site. I also certify that all Information provided on this application is true and correct,and tgat all regulated activities will be performed in accordance with all applicable SAN <br /> 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 at the <br /> above facility/site address, I hereby authorize the release of any and all results and enviroomenol assessment information to SAN JOAQUIN COUNTY ENVIRONMENTAL <br /> HEALTH DWISION us soon as it is available and at the some time it is provided to me or my representative. <br /> PRI <br /> APPLICANT NAME ! SIGNATURE <br /> TALE DRIVER'S LICENSE# <br /> �" JPFw7Tf7MPY AF[]I I1mFRt <br /> a <br />