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DF.TE M&ER FILE RECORD INFORMAnoOMFR" GREE,FORM <br /> UNIT IV <br /> OIRNER FILE <br /> a(PI.E7rTHEFOLLOWNGPROPERTY OWNER /NFORMA710M.• CHEarIP OWNER 0wvAzArnrtwftjIuyrHEHO <br /> PIIOPETM Pr e <br /> )WHEN NAME <br /> M y <br /> N" a TBPOE of W. Lodge 10116 Boc SfiolTAZ IDN <br /> wrier Home Address DpAvews UcEmsc a <br /> ity - STATE <br /> P O.Box 691985 <br /> ailing Address City Stockton S C4//,- ZIP 95269 <br /> FEDAGEN"ORFOMTIOH(7 t1101W1a{/AL❑ PARINfiRWa❑ O MIERs <br /> 1AAC1L1rf4tL1E <br /> PwaZ *�a* '; ..�,.�"lrY�'".�'*''.- ''WOA�'i6.,. .,t .tau : •.:,,;.,>.r.:,+..,. ,. +y� r't'v'$ <br /> MPLETETHEFOLLOWrNG BUSINESS/FACILITY/S E RMA 770'-F <br /> this a NEW Business LOCATIDN not previously ragutated/tiy tin Al HEALTH N? YES ]4 No 0 <br /> this an EwsnNc Business LocATroN but a NEW TWE efregufatlyd Bus a 7 YES 0 No <br /> ummEssfFA(atrtrlSvrx NAME N/A / x <br /> inA.bDREss 315 S. ;Center Ave SUITed BQ0ftUFM0NE <br /> ATT - STATE Zip <br /> Stockton <br /> vL CA 95,212 <br /> Ap - ..Er1:3:.1• .:� f18P'wasc; �� •�''`�9` <br /> failing Address NO/FiERENTfmmF o7�AA4Aves AtfanNon� o/Care Of/optima!) <br /> tailing Address City STATE zip <br /> 'IC NODE?''ui;)`S yA � •. . �1'�•c. _ 'tb4.. �t, --;I Y'riC�»4% '4:.;y � .�"� �.!,f i✓ <br /> ORD PARTY 13ILLING 1 O: Completed Boling Party isammerentfromPropefty OWner or Facility Operator AMMM;falAom <br /> :LMM s NAME Altentlon:drCare Of (opbbW <br /> CL P O erties, VI <br /> Cammack <br /> InIlIng Addreas g 27 N. Fresno St. - <br /> PwHfi 559-437-1333 <br /> 'm Fr sno - STATE CA Zip 93720 <br /> for fees and charges OWNER FACa lBUSINESS THIRD PARTY BILUNG <br /> 1.IN(:AND C0Mr✓JAN"ACILWOWLEDCMENT: L the undersigned Applicant,certify that I am the Owner.Opemsor,orAuthodmt Agmt of this Bwaften,And I eck°ewledge that A] <br /> PAIR Ft Bs,PENAL77n ENFOAC AMYTCHAAGZT And/or 110411fr.y I.NARG"AMocloted Nna IDH Operation war be bIbEd to me At the address IdenDned above AS the ALUVWAaoABt <br /> This bile 1 Ab0 teAlry thin All Mfarmadon provkled an this application is true and Correct:and that as regulated setivitiis wall be pertorared in amnlance with All Applicable SA! <br /> AQum ODiwry Ordinance Coda Similar Standards sad STATL andfar FEDERAL taws and ReguhliDDL As the underaigoed owner•operator,or aged of the pmprr(y lowind at Ih <br /> ne e.dnryh a nddre>,, I ksd7 aabherim the nlaa of way wad an "nn"'And IwvlrennacwlN AbeMwwbel 14APM411eA b BAN JOAQUIN COItNW ENVIRONM )'"Al <br /> 'ALTH DIVISION b woe an k la Available And At the pale time Ilia provided to The or my repreeentadve. <br /> /�///' y J( PLEASE PIaIrt <br /> ,p►LICANT NAME / &r l of l o SIGNATURE /A — <br /> / 11�� <br /> ITLE rAl< I ✓r37t}clan^ �u Viser' DRIVER'S UCENSE , <br /> 'Pod QY''z/.�.. _ �et0 n' „rte .��y•:•y: i •�'.n . ..OHbe i'roasii';....C.w ,�}.�J. c �r+y � ;ti+u 1 C . •r<:j S-:. <br /> TOTAL P.05 <br />