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0-1- <br /> DATE• _ �- � �. v_ir_. •_ i.. <br /> MAS f�R FILE RECO INFORMATION "IV�FR"'V` GREEN fORM <br /> OwNrut FILE <br /> UNIT IV S3 <br /> rAIiE7Y Tii1-01 LOki PROPERTY OWNER fNFORMA 770N.• <br /> PROPERTY H OWNER 0"s`o` rzTVNfttyrHEHD <br /> TONER NAME PdoMe <br /> M <br /> Y <br /> °AED°N"'eE IBPOE of W. Lodge 101M6 u <br /> Boc Sccl TAY ID,T ' <br /> wrier Home Address <br /> ly <br /> Acer Naawa A0.Ma <br /> P-0-Box 691985 STATE Zm <br /> aldrlp Address City Stockton <br /> - - Stat» C.-� Zip 95269 <br /> 00110 ad O INdrvretrAl Q PA117eiww❑ <br /> FACILI Y FILE O OT"ER 0 <br /> o - <br /> J�LE71�nfFFOLcowrNc BUSINESS/FACILITY/SITE/NFOAManON. <br /> this a NEW Business LOCATION not fxevh 1 reputeted by Ute ENNRONNEWAL Hiiii DrvlsaN? <br /> th8s an RtIsTiNG Business LOCATION but a NEW TYPE Of regWated BusMws 7 YES 0 No p <br /> d3a1ESslfAatnY•tSITE N"a N/A Ii -a- YEs p NO;rj <br /> +TEAI]DREae o <br /> 37 West .Sonora Strt=et :. , Stn i Bt�11�ssPNONE <br /> :ITr <br /> Stockton <br /> • l reg Addreew HO/FFER61yTfiornF STATE CA Zw 95212 <br /> �i` <br /> 6710_- - �tISEJ� tu`&.',:�. Irv'M;Ai •- -^ ,,.:,. <br /> W <br /> @, <br /> Attanuan! 0r Care Of 7Opfi,,i <br /> Isili Address City <br /> STATE LP <br /> iSE•.:+1:sins v <br /> nImPARTY BtLLINGINtot Completeil8itlingParty /sd/lferentfromPro h f r <br /> tmum NAME party Owner orraclllty pperator 77ent7/7ed epti <br /> CL Properties, VZ Attenhon:or Care Of <br /> 1e11r'RAddirs" 8227 N. Fresno Street Ms. Chris Cammack <br /> Fresno PN wi; 559 - 437 - 1333 <br /> STATE CA zp 93720 <br /> lct7!¢6Ql79f.4F for fees and ChargeS OWNER FAaLnylBustNess <br /> IIrrc,rrn rnM.l,ANcx AcaHowl.AvGMENr. THIRD PARTY BILLING <br /> W?f7Af.PdNALi1R.EHFORCS{r6M f7ldRGLS AAOMr!%1 RIS.rCHA/fP LPinnl,arti y that <br /> 1 xm the <br /> tAu aita i abo ttniN that•II MforuatbA awetaeed with thl. err' ' or,or,trra4o.tudAarnlorrh}� _ I.elwo�. <br /> Provided on this• operation win be Olney to me aI the atleress W mtlllyd ledge that.4 <br /> iQVnr Co1+em Ordlaar,ee Code Awdlor Standardr and STAT�a�ofoFo'E�pC�ewLALaws a df;and that an Midided <br /> Aa 4e adders'ilio Iii be rio a�as tee,eccrwrcrnnnAexs <br /> "'• �ryhhe.ddPe nrled in areerdawre with all.Iroiicabk SAN <br /> ALTH DIVISIONaa 1 4.eby .iind iar M. r0r...o1 .nr ..d .n re..ib and envinnmewl.l Swed Omer•operator.or agent of lM properly Iwkd al the <br /> won u h u a.ailabk and at the ams Iime it a •"•�a"'ael 1•far.n•do• a SAN.On IIIN <br /> '/ provided to me or ray repreMntadve. Q COITNTV ENVIRONMENTAL <br /> rrL1GANT NAME//-lr �• ro PLEASE PRINT '/ <br /> ,`-C f{ SIGNATURE GAI L{-- <br /> ITLE /- y tt!///444LLLyy� <br /> !df �A'dISrY ORIVERSLICENSE/ <br /> -- -- T&AL P.05 <br />