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I I r • <br /> San Joaquin County Environmental Health Department <br /> DATE 5/ IZ o`� MASTER FILE RECORD INFORMATION "MFR" GREEN FORM <br /> russf <br /> It� <br /> Sui ansa wla F1411 UNIT IV <br /> OWNLIR FILE <br /> COMPLET7NEFOLLOWMG13RIDPERTY OWNER INFORMATION: Or£ofJP OWNER CUAArm ron me wTm END <br /> PISOPeaY Owxat NAME ,�,,,, 5 k ey'% C re-e \ PHONE 3 Z} / 9 4 <br /> First MI Last / <br /> BUSIIIBS NAME IA)ttA kjnSGS �,rOrw'W SOC SEC/TABID# <br /> -ItPt.c C7a66ga�(LvAr-� <br /> oa,msr Hone Address I-LG86 N Gfn YV� .+V-f. DAsvaws LIBHt# <br /> City LO U STAIE C,4. ZIP C� r^L`(o <br /> O,xrw Mamn¢Addresa byp N , EL Do'r'ade St. L `] <br /> Mamtap Address City k�-rnn Stab C e4 TIP „q 5 z o z, <br /> Ccosma imN❑ I- PAn11QILA1a� Fm Atilxr❑ OnER❑ <br /> FACILITY FILE. <br /> sAEYY?P#i LcE cAospeFlgx itaooulrw- , 3��� tr� * l $RS' <br /> Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ No P <br /> Is dds an EIOstrim Business LOCATION but a NEW TYPE M regulated Business? YES ❑ No,SJ <br /> BUSafs/FA^ jSRENAME F611,421 U,P�� U-abba rd 1'r.c . <br /> SREADDnESS S1mE# BIIgDESS PHONE <br /> boo n/. ^ <br /> SEATE C r'i 21P 9 5 z o 2 IX <br /> .rr77177771 <br /> I <br /> 4� <br /> Mallltsg Address lrOlAtFRENTrrwn Fad/ltyAdbeFs Attention:or Can Of(goF/aWJ <br /> V 33$ Ue¢lA_ rat;,\ circles -�D/}rU F3J3L[-IZ1� r,� <br /> Maliing Address City 5}o L k�w� STAIE C A zip 15 2 0 9 �1 <br /> C� <br /> THIRD PARTY BILLING INFO: Complete if Billing Party is diffemntfmm Property Owner or Facility Operator idendRedadore. - <br /> BUSINESS:NAME zero A - Attaa <br /> ,Calm Care Of(dpolarsa) <br /> lTro��d r`«I.itl S <br /> ManlnD Aeanss k7 14 PUKINE 60q)83 $ -cI9-6-b- <br /> AGCawfZ,AAAAW for fees and charges OWNER FACILITYIBUSINES$ THIRD PARTY BILL NG <br /> Nnuser.ANn Ce1MP1«NrFAr NDWFFWr FW: 1,the underaignsl Applicant,certify that I am the(hwner,Operator,or Aurhoriud Ageof of this Business,and l acknowlege a PEAK-"-, <br /> PEWURQ T,£NF0ACE&tFWC)LRGrs and/or NOUALYCNAA4PS associated with this operation will be billed tome at the address identified above as the ACZVUNrAnnRCW for this site. 1 also certify that <br /> .it information pravidrd on this application is true and correct;and that all regulated activitia will be performed in accordance with all applicable SANJOAQeN COUNry Ordinance Codes and/or <br /> Smndardsand STATEand/or F..EI Lawsend RKulations. As the undersigned owner,operator,or agent oftheproperty IeuteA at theabove fadliry/cite address,I hereby• thosiu there lease of <br /> any and all result end environmental.,,..carinformathan to SAN JOAQUIN COUNTY ENVIRONMEN'rAL HEALTH DEPARTMENT.s Hble soon vs it ie Avai • vt the same time it is <br /> yrovided to me or my representative. _ G/ <br /> APPLICANT6DR <br /> NAME �-t y (�' r'N( •r1HL <br /> SIGNATURE <br /> TITLE `/, s7` DRIVER'S LICENSE if <br /> V (( fRgfDmPY NBGUa1ED1 <br /> APpavad IN DUES A..M*Off.PratsanWlq Cam~By Dab rJ I g 4 <br /> 29-02-002 Ap H125,2003 <br />