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03/232006 12:13 GED< IX—RRNCHD CDRDOUR 4 12094683433 • ND.147 1P02 <br /> San Joaquin County Environmental Health Department GREEN FORM <br /> OAS 7j /Zo 10 b MASTER FILE RECORD INFORMATION "MFR', <br /> wn r��. DwNERIDA 4 �y U� UNIT 1V <br /> OYMER PILE <br /> tNFor,rF owlvER teraRwnrar snu w—E" <br /> NPLOF THEFD LO Gp ERTY 0 NR7RMA7YtlN' <br /> PaapmsT OwrmtNAMe �jy.y, 1044 R.d <br /> Fuer M Law <br /> y,�u $DC$Ec J TA1IiD# <br /> OWnet'PlDnte Address /6 o d 5 /�'� �0.J S : Israeli I scusi1 <br /> MY � <br /> `��� nArEca 95zoG <br /> Owner'Neill"Addrenc y,.,,. talo C%,A- <br /> ' SIahO TJp <br /> NaIGng Atltbu6e CIIY <br /> CAapaRaTrali� Dhal'BAIAa❑ PARMERanN❑ PmlweHdQ OntmQ <br /> FACILITY FILE 3a6� /?I G0.a95R IIID# A=0WTII1 9 (eit t"r� <br /> FACS0.T'ID# J <br /> E <br /> Is this a NEw Business LOCATION not previously regulated by the ENwRONMENTAL HEALTH DEPARTMENT? You ❑ No <br /> Isthisan E=711ilE Business LofATION buta NEWTYPEof regullatsd Business? Yas ❑ RD lib <br /> apmras(FACAtsv/SIra NAMe SrP'YIS /?ret a ,Vcr14 <br /> SSMAm St , <br /> Carl, Bay"" y8 h'oro <br /> sT--eA 78 95206 <br /> BaARa oP Supmnsox olsrRlCl I.X&TION Gane - KEv1 NM <br /> Madling Address HOJrF&UWficvll FwWA'Ad7mss' Rpetltlnn:42' Care Or( Imrat) <br /> STo1E LP <br /> Malling Addresi 2 <br /> sic I� 0o ` -STKn� APN as i s t 7�DZ��i raNHeRn <br /> THIM PARTY BILLING Hill Complete if Billing Party is different ffom property Owner or Facility Operator idenWed above. <br /> ALLSiNE55NAMe CAMMIllan:wrareOf (apeonaI) 6r trrG H.u.. <br /> D��,d <br /> 1 dKL. <br /> Naelrtg Address rad i a w"T�e^ J'�-p 'tee' S"S G• foo PNaN��16 d;36 -,?2d8 <br /> C'^' A&V( 9 <ordorVa, S1AaGd 9Sy 70 <br /> for fees and charges OWNER FACILITY/BUSINESS r-aTNIPII PARTY BILLING <br /> r wva�amar; Lmormdenhdnad Apppcanl.ctrllfy mntlnm she lAme,lyemroq or APPAodrnd APs^f or tide➢winm+i aodd otpnewledpe Inertia Prooar FW, <br /> dr'mrN <br /> PFNALnaJ'FNPaIpSGNA,/rC/lAALTr pNIrnYHOnRLr r./fARCEP oSVKiyleO with Ibis npernrJln will be biped l4 do n1111C address idaPpfifd oOoyem the -4Aast[{' <br /> tOr mlv BnC lelre cel 01 <br /> all laronamuen praMcd on Lpia upl ims is woe end correetl and'but oil mONawl a,Aoidea will be perroemed in ntNrdpneo wall nil applleshla SArc JOWN COXWrY OMiamme Codes Cellar <br /> Smodarda and Store smaller IE08RAl.Laws and geeuWhhme At rhe unaereldnntl owner,opaater,or need orate property heated et rhr atmve fncniNlsire address,l hereby mahorize the release of <br /> any and all Coda me,envlronnrcnnl nrsarmene Inmrmapon to SAN JOAQLIIN COUNTY ENVIRONMENTAL IIEALTII DEPARTMENT m soon a it in nvallable and at?be same time II'io <br /> pro+late to the or my reprmenratuc, PUAsn PMT <br /> APPLICANT NAME rce 4-11swen <br /> _ 51&'HATUNE �C " <br /> TITLE c DRLVeRS 4tCEN4E d2 <br /> -+ -- �+p� rPMOTOWPY RE01nPeP� <br /> ?� ala a f o <br /> AaPravat Ey Deal 27 0 re Asn tLg w-proposal,CnmWeted eY C <br /> jg02AW April 25,2003 <br /> r <br />