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0 +r <br /> _San Joaquin County Environmental Health Department <br /> DAT` /i o-3.�3 MASTER FILE RECORD <br /> 7I'INFORWI-toNN "MFR" 1r''RFEN'yF'OR�Mp <br /> ffyggE&2nEwe Go"g ILO u4e Y OviNER TDO / �!_�2 I CrSEY "�^� ��� VN' 1 'Y <br /> �C+WMER FILE <br /> CojwLEm niEFoi i ow/NaPROPERTY OWNER/NFORM4Ticim CHWKIF OWNER CUWRE ,Y0$nUwnH EHD <br /> PRoreary O+mERNu+E - PHaNE _�25-35'S/3rJ5_� <br /> FI+Al M1 Lnsi <br /> OwlnrNwna Add(+mej/77�"[(Q•(OJ(v�/�r�y�/�y/�/E�6 I E•�+I•' 7l�.ZC� DrnrErs'sUDr:Naell <br /> / Srere A�f Zm <br /> OwrerMMIRY AddrvaA ` ,rK//� fJI NI�`` <br /> MNlinpA 111_Gllyp� /G• bY61e I Zfp <br /> CONPDRAl//1bN IBJ ^'^� WoMWnt❑ PARTNERSHIP❑ FMAGENCY❑ OTHER❑ <br /> eft' r(o ottt Nl96YN 2803¢- FA 2.3$�,jo MiNy <br /> FACILITY IDY �CRoac R[flbry ' ACc6U�IDN —��_Y_`� :INvl1 �e^��p"s-_G <br /> COMPL67E TwFOLtowwya BUSINESS t FACILITY I SITE/NFoRMATION.• <br /> Is fts a NEW Business LOCAnola not previously regulated by the ENVIRONNENTAL HEALTH DEPT.? Yta No ❑ <br /> Is this an Exma Badness LOCATION buts NEW 7YPE of regulated Blcsfness? YES ❑ No <br /> 1 auNlNEaslFnc1utt15rrENAME �/fi�A/A�h ,S{/�!b —, - <br /> SC,fT1EY AayD'R`EE/ws/sJ/Yf13AW404 aunEY BUMESSPHONE <br /> STATE • 7_IP 7s•3�? <br /> •fdDAPa DFaUPERVIEOR Disrl� LCOrlT1DNC=q� KEY7 , _ �KEYl —_— <br /> MEINnO Addnaa.ti0/FFERENTfrvm Fwc//xyAComss F-�`I ARE"..!aY O.m Of(op&.q J <br /> Malllna Addres City STATE 21r <br /> COMME[n <br /> . - — <br /> THIRD PARTY BILLING INFO: Complete ifBilling Party is different from Property Owner orFacifity Operator iden6fiedabom. <br /> SUMNf3R NAME Atterdlvn:orCare of(op / <br /> IGih ll lee:, //�� f_, P_G O <br /> MMNrg Addrvsr a/ "( tit)1-nvrr led1>— ��C I PuaOe dr g- N $` S <br /> Cm. C�SI'ATE ZIP _/S �b <br /> OG+C T['TAf� <br /> &=D N&M ERAS. forfamwd Oarg88 OWNER FAcuiw/BUSINESs URD PARTY BILLING <br /> Ei11.1AN(i zltu Cu! 1p'A['AN t'mENv` I,Rle undmirysel APPGeu,i,4,yi(v dut I am dK(hno,O'+uynr,nr.lnNbluMAgfnl Uru:u Mafan;rrui 1 arknoadcd�E U:>t•ll PdN/fF¢.s, <br /> YFiutnn',ENfDRfEe:EAT CMANr.ET pnd/vr NauAl,(CRAAr✓T+P-�Uculd tiith Yee nperu4vn.viu lie Lilkd b me n1 Nc rIW�edrnfific!e6vvc as IbeA[[:x+m'AnmePrT lnr dui ule.I Also cerEf)6nf <br /> dl iv(ormAtiov prn.idvd oa Nu vP1lEndvA'e Iru:avd wr-a4 gad dul W,Xnlnta(vrli.iSn witl Gn Pmlenned c:rccurdwlx w'iol all epplio6le SAN ruAUUM CUU ONi.n Cuda Aodfa <br /> $undnrd>:md SYnn:Andlvr riDvn•, [avYr end ReguM!imac A>d:elmdenipW owner,rllmun,or Arent n(d,c Praperry IoG1vl M else nM.c iadlisy:'sic eddreu,l Lvrelry>u LLmri�a,e release of <br /> eny vnd A11 S.,.Ifsand ttrvicunmen W exe.mra[ie4,rn"fivv cv SAN JOAQUIN COUM V ENPERONNIENTAL ITEALT11 OEPART'b"f v Loon as it i.Ar�l>tde Avd�I dse�avu time it u <br /> pr <br /> APPLICANT <br /> NAyrtpresrnl>Ea= � •—��� <br /> APPLICANT NAME(��L��(�( � SIGNATURE <br /> TITLE DRIVER S LICENSEd <br /> '� �/!1'T/ Y��J � �� (GHOTOCCPYI i-0I11REo1 L.=J��t. <br /> rwProYAdry <br /> 00, _ .nneoaA. T orc Proclsl Ycare�l aav �_- w[G(/I D.a �{I �3 <br /> 2902 10/12.07 r — MASTLT:FIL�.�7f9U-GRGEit <br /> O�/ V� <br />