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"TEygMAS- FILE RECORD INFORMATION " <br /> FR" �R�H FORM <br /> i@TGka --r <br /> UNIT IV <br /> OWNER FILE -' <br /> 7NFLETE rHE/0LL0W7lVQ PROPERTY OWNER INFORw TION.- Clw-MAF OWNER C+lalrEt nycwrx&wrHEHD <br /> 'ROPERTY p/pie <br /> vNFR NAME <br /> r..t <br /> JNEaa NANE IBPOE of W. Lodge 10106 soc scc lTAY IDs <br /> weer Home Address DRrvER'S UCENIF <br /> STATE Zm <br /> "^'r7A1""g^0c`Pa' P.O.Box 691985 <br /> ho Address City Stockton Stale CA Zip 95269 <br /> ronwvaN 0 IN C)UAI O fat fiaa 0 FED ACU40Y❑ QTl1Ep❑ <br /> l FACILITY FILE <br /> 'wY wzR'.R?cA>.>.. - .. �' .• .>; _ rp ._ `, <br /> IFLETETHEFOLLOW/NG BUSINESS/FACILITY/SITE INFORMATION.' <br /> is a NEW Business LOCATION not previously regulated by the EwRoNNENTAL HEALTH DtvlsaN T YES 0 No 0 <br /> this an EXISTING Sualnesa LocxnoN but a NEW TYPE Of regulated Bushross T YES 0 NO)o <br /> NEsstFACIUrTISITE NAME N/A . <br /> TEADf1REs9 SUITES BUSINESSPHONE <br /> 37 West Sonora Street, . - - <br /> Stockton s STATE CA Zw 95212 <br /> 1: 1 <br /> �2A!Bf?ERAP.2. £ � <br /> i. ` ` £/� <br /> — . '3FSAImH4�tadx4n <br /> �ne Addro.a/107FFEREIV7`15 n Faod,OAddrdas Attantldn:Or Cara Of(opbo ,p <br /> ng Address City NATE LP <br /> .'.'�.OISE�'vi,)'S`.1"it i F. _M1'IV w aq�otW" t' i.�•'a �S�tliic�'$s5i c-s�� e T i TyviT..., v �: <br /> ''D PARTY BILLING INFO: Complete d Billing Party t9 d/lferenl from Property Owner or-FaCil ty Operator rdeNtrfred eDOVe- <br /> am NAre Atteridw.wCare Of (opb- <br /> CL Properties, VI Mr. Chris Cammack <br /> •-"ng Addross 6227 N. Fresno Street <br /> tr.toNc 559 - 437 - 1333 <br /> Fresno STATE CA ZIP 93720 <br /> OUNTA0,28M for fees and charges OWNER FACRr1Y/81731NESS THIRD PARTY BILLING <br /> INC AND("A"PIIANOt ArkNOwi rodmENr. L the undersigned AFpllelRt,certify(hat I am The Owma,Operator,or AalUdledAgmt of this Roslaent sod i aekaowledge that aR <br /> frr"&T,PSNAL77M ENfORLEA/dNT t:7fAM.'1R sad7or rlovAl rCNAf4ZT arsoetsttd with tell OPentka writ be billed N Meal the address Idmtipto above a the ALTTWATADDALIT <br /> silo 1 also Certify Chat all Informtloe provided an this application Is hoe sad correct;sad that as r¢alated adiviliis mil be performed is Amrdaaee with. .M.ppsabk SAN <br /> n CbONTv Ordfiia a Coda sad/or Standards and STAT[and/or FEDERAL Law,sad Regulation& As the anderatgned owner,operator,or sgenl of the Property looted at the <br /> ► ftl%he"dr 1 b-1,7 -o -Ase Ms rdaw or..,y nod NI rawM end en.ironmrwlN wru.wsat lots 116a to SAN 70AQVIN COLRJrV ENVIRONMENTAL <br /> LTH DIVISION 0 won at it is ovsibble and at the Mak time It is provided to me or my npraeeudve <br /> C PLEASE PRINT <br /> .IGANT NAME Jkrry / III dSIONATURE�/�y �n <br /> ,I f <br /> IGI J �1 G er` ✓75J�' <br /> DRIVER'S NSE0 <br /> eunfYYa OMed-Pr+emiiisa Cowel� ut" LCri,.'.�JR. iw`�'iYY` w:R:+•,:-"PaR»..F%•. <br /> TOTAk P.05 <br />