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ATs. = MASFILE RECORD IHFo:.RM.::..,ATION.�.... "VR" GRE" FORM <br /> UNIT IV <br /> OYYNER FILE <br /> mPLE7rn --,-0LtOm,V0 PROPERTY OWNER Avroim,477om- ChrcKIF OWNER CuxRxrrravr&EmmEHD <br /> 7 <br /> Rt}PER7Y <br /> plwate"NT—YE <br /> - <br /> n+e4sN'"A'E TBPOE of W. Lodge 10116 SocSEc/TAxID* <br /> wrier Nome Address <br /> DlttvliR`8 LICErtSE 8 <br /> STATE ZAP <br /> r ssankwA00r@1! P O.Box 691985 . <br /> ift Address City <br /> Stockton Stale CA zip 95269 <br /> MTION Q fRDMOVAL O PARTNERSHIP❑ EEO Y Q R ca <br /> FACILITY FILE <br /> - <br /> l=Apt db�.�' .•_-.f:i'`� .�.s� � S;REit ld- �' r a .�:�lai.;i_ � °�i�'o� '�`�' ,); ;:S'��� .t,t�.3�:'�`,�� <br /> p�ETE THEFOLLOWiN0 BUSINESS/FACILITY/SITE INFORYA77oN.' <br /> s a NEwSuslness LOCATION not previously regulated by ttte Etrv1R©NmENTAL Kt6ALTH DlvtstoN 7 <br /> YES No p <br /> this an Ext"NG Busln*rA LocAn(m but a NEW TYPE of regulated Business 7 YES p No <br /> Ess/FAG1U YISITENAME N/A <br /> trEAlinRess 315 S. Center Ave_ Suite BMAMN/A PHONE <br /> Stockton STATS CA ZV95.212 <br /> 111411 1 1,11111 <br /> ung Addroaa MAIFFFRGNTbvm Fwarlio Ao(dro" Attantlnn, or Care OI(opUonel) <br /> ttg Addreae City !y'7ATE xIp <br /> n;? -4'4tr<sS <br /> t :gin. L...,1`•�i�� -x <br /> PARTY BILLING INFO. pleYt'e�d7 Bi1=ing Paty f9 4fereni <br /> f fnPrOpeM n.e...r o-GrFAy�aCf?t+l#ei+t'.:y..?Of�.p$'era,-troe�rAiLI;Ud2'.' <br /> f=ecom <br /> abov <br /> e- <br /> NAME CL Properties, VI Attention:or Care Of (cp6oaW <br /> TT;3Tl G C}: <br /> Jig addreas 8227 N. Fresno St. <br /> P.Aorer <br /> 559-437-133--- -- <br /> Fresno STATE C7; ZJP 93720 <br /> _ for fess and charges f, YMER FACII_1TYi`BusiNES$ THIRD PARTY BILLING <br /> JIHG A NR CC?HFtJANc.x ArKAowtxbcmENT. L the undmigned Applicant,certify Ihat I nm the Ovrrer,O wWor,or Aulhorizsd Agml of this BuAntn,nAd i acknowledge Chart A14 <br /> ¢Al1TFF$1 f BALtIT7hS ENF()RLaa71f1�TC7fAlIGCYayQ/Or 1I17L'Jtl.!CH[lr(i£T txlOclySed w4iA SOIL nPrr bn N111 d*pilled tO me St the addrC3S We0111![d/54vC aS RU A(MYNINTAX)AEV <br /> f ie. I"130 certlfY Ihnt illi k1Sat>yradon provided an this awficstioo is true and correct;and that all regulated activiliaa rn71 be perfonRed in ACftTdanCe withal]alrpficobic SAN <br /> s C1)imw Ordlnanee Codes natdlor Standards and STATr and/or FEDERAL Laws and Recolatloms. Aa the andenigued mracr,operator,or agent of tlw plmperly located W the <br /> �51110-nky/alte&ddress, I L—c-by mmhori= the release or my .ad all rmwlla wnd mvironr ental aeeraam.eat lwf rw,6110M to SAN JOAQUIN CC)1WrV ENVIAOulvf EPNTAL <br /> ALTH DIVISION is noon as k is available and al the same thin It b provided to nw or my rellraet(Adve- <br /> Pt EAsr<PPJNT <br /> ICAAIT NA1N€ { .{� SIGNATURE <br /> ! 1 l I 40 <br /> ITl E a nIN57I #14a,j1� ;5 )ser DRIVFR`5 LICI N$E <br /> � -Qttt�B�•, 1... 4` •��.. `13ff1o�brwaeas .w.- D..°-�"���f�.-..��,h_7✓�sr��'Xla. R4.1.. -LIQ.,:�'T`-�. <br /> -___-•. TOTAL P.05 <br />