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s,S:...'�'„_,"� '��a:'�`;lam � _�•^''��.�":;�.- .. z'; sJ'.-r�:" `_ <br /> •t A !. <br /> e s r G r iR F, .. :.,.r ;,: r u a 3 _ M[r'••:3' �� - ` �a FORM (Moo 1s[RIYamOT11 srs7) <br /> oATE � � ,c � .. '� MASTERFILE RECORD In11=oRMATIOI�� "= <br /> UNIT IV <br /> OUVNER Fl •:� r <br /> CrwmviP OWNER CWmVmroovmffwrrNEH1D <br /> COMPLE7E7NEFOLLOtWNGBUSINESS OWNER INFORMA770m, <br /> - BUSINESS -�' +� '.4 ^ � •• 1�T�/ ',. � N <br /> OWNERNAMEAO <br /> '� ---- � --- ---- ----- t/ <br /> Busimms NAME(d dWer+aent from Owner pName)': VVSOC SEc I TAX 1D S : > <br /> OWNERHoMEAoureEss *per y yryx DRnrER'SL1ct�esEll ��a? �:.e <br /> ami <br /> CItYy7�� p :t; ZJPr�2 <br /> 3 a wV� a <br /> OwlliER MAILN6 ADoaESs (ifDIFFERBVrfrom Owner Address). _ �. - Attention:orcare of (hpNonag <br /> MailinpAddressClay ZIP A` <br /> �: a, <br /> CORPOItAT1ON 0'^ 's'INOlvrtnrAt D 0ARTNE7tSNIP❑ LOCAL AGE ImY o couprry AGENCY 0 SPATE AGENCY❑ FED AGENCY 13 OCHER❑ <br /> FACILITY F14E <br /> A <br /> COMPLEmTHEFOUOW/NG BUSINESS 1.FACILITY I SITE INFORMA ON.' <br /> IS Uft 8 NEW 8tssiness LOCATION not previtnlaby regulated by the ENVIRONMENTAL H DIVISION? YES 0 NO <br /> is this in ExtsnNG Strsiness LOOATIOM buts NEW TYPE of regulated Business 7 YES p NO <br /> B=NESSIFACILMISWEN"E <br /> SITE ADDRESS ..-e�`rAr7 , "- � � _ � � •surr>~# - BLnRp <br /> ESS PHONE <br /> �/� <br /> i <br /> S1 <br /> Malting Andress ifDlFFERENTfrom Faaft Address �Attentim ar Care Of(optional) " <br /> Mastirrg Address City -TAM' 21P <br /> THIRD PARTY BmuNG INFORMATION: Complete if Billing Party is different from Business Owner Idem'led above <br /> t3uslNEss NAME AttenUom arCare Of (opffaw# <br /> Mailing Address PHONE <br /> } . <br /> STATE ' zip' <br /> AccauA{rAanRess for fees and charges OWNER FAq BUSINESS THIRD PARTY BIWNG <br /> BMJ.JNG ANt1 COMYLL4NCE AClarowtMKMmfr. I,the aodn:igned Applicant,certify that Ismw lative. <br /> wns,Opwwor,orAm*orkedAgad of this Basions,sad I acknowledge that all <br /> PERwrF=PFNAt:7TES,EjwoRcDiE CuAk=aadlor HOUXLYCHARGEN associated with this olan M be billed to we at the address identified above as the ACCnUMAPDPX5S <br /> for ibis silt: I also cerd&that all lnfortuation provided on this application is true sad correct;andt all regulated anivitim wall be petiormed in ateordaaec with ail applicable SAN <br /> JOAQUIN COUNn Ordinance Codes and/or Standards and STATE and/or FERAL Laws and Regas. As the undersigned owner,operator,or agent orthe properly located at The <br /> above faailt Rite address,I hereby aathortme the release or any and all resalts sad cavirool.amesemeot information to SAN JOAQUIN CDUN Y ENVMONMENTAL <br /> HEALTH DIVISION as soon as it is avm&bieand at the same time it is provided to are er my rep <br /> MXASE PRI .. <br /> APPLICANT NAME f SIGNATURE <br /> DRIVER'S LICENSEf <br /> 'RILES ' s la,.nte,e nvrsraeenwr nl <br />