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_ San Joaquin County Environmental Health Department <br /> DATE GREEN FORM <br /> b'-zh13 MASTER FILE RECORD INFORMATION "MFR" UNIT <br /> ' <br /> FdEHF.2P_aeAe ra.ENO ube a it pWNeea 11X CASE# "I` UNI I`� ISI�/ <br /> OWNER FILE <br /> 0oxPL57E7H®fmLowjvGPR0PERTY OWNER/NFORAIAT/ON: C0IEXr1F OWNER CvitAdNnrdNTttFWRM EHD 1 <br /> PPDPERLVOWNEANANE t't10NE —SSS�'�OS-J <br /> Flmf MI Last <br /> BuammNAae /s�/j�-; /ry'� )�P BeeSEelsulbf <br /> DwA�"°m°"dd"'a 3oov /�'�'>��� .fir J�33o ORIY82'6LLCENECIf;----� <br /> $ATE n� Zlr 4�Sdr3 <br /> Oumm MMlne AAdross ISARN�+.� VI <br /> MaiI1tLY Addrma CRY Stela Zdp <br /> COaPOaAnON� � MBMmIu❑ PAmxNLSNmO FEnAOtinw❑ bRIEA❑ <br /> ��I�r '(a 0(a� IPcP6au Z 03'f- FA 7 O(•FIVNy C— (� <br /> FACt13TY IDM CRIMNRrF Ib# AOCOUNTID@ INA - <br /> CoMPtEwTHEFmLowiNa BUSINESS/FACILITY!SITE hwowAwm.• <br /> Is this a NEW eusinese LOCATION net preialously,regulated by the ENYIAMMENTAL HFALT14 OEM.? Yes No <br /> is this an EtasnNe Business LOCATION taut a NEWTPE of regulated BusineSS? Yet ❑ No L7 <br /> � $uMxmslFAcnlTvlSRENaEE G/f�N�� ,�/�d' <br /> SrrEAOOpm 77 /' /_'O �1 Gum# Buswu3sPNONE <br /> cnT GH/t.Y�w'//'�i/'���iii���??►► N74 iY STATE A/r zip <br /> B04RPeF$YPFRVISOA DUTxIm �� I.DCATIOry GOpE i( EYI NEl2 {�' <br /> Me4lne Addltsss/lOfFFERENTfian FnciN[YAtklnrsa y C Anartion:ar Oatw OF/apfiara/J — <br /> Mailkg Addraao GlLy —_— STATE Zn <br /> SIOCOoe APNa�� Z( _03 COMMEM.. <br /> THIRD PARTY BILLING INFO: Canp/ete%Billking Party is different fmm Property Owner orFacility,Operator rdenfTedabove. <br /> SUMOMNAMEAtlmtlon:OrCata Of(ep <br /> Ie-; le,, c , <br /> MCIIItg Addraar PNONe [L� <br /> o70D/ B/DD o' � <br /> Om. T G-igSTATE Zm 5��-ZC>L <br /> �y'rA'INTAn Fee forfeusaadcharg" OWNER FACIlMMUSINESS THIRD PARTY BILLING <br /> an.L.M(:ANO�Qf1P uN(F Aex�'mh9.PtnxmXr: 1,tllc neWrnirPdl ApBliunl,W'fily dut 1 am Ib[(1nno,Oir fir.ur,1_laorvtd Afr//f of(leis Nntm¢q eW 1 aClno.dvdp,!iluL[p PEAM/f F£PS, <br /> AExaLREti,En'PpMG:Fx'CRA6a6 And/or Havas CnAAen'ax+ariated wiW S�nF+tattoo rvin lie 4ilkd m ne a1 W[nld,v idmfifird ebme az 1b[dccrurnrAnnene<!nr Otis uia!LLw[ertify Nut <br /> al]ief.multiov Pnvidd an ex,NPPlitae'+•b1wa.4.4.4 data Ali�hed neivida wie be pe,lonned m ICTAd�with an eppik=1bIC SANJOAQUIN COUNTY Ordnance Codes..Alar <br /> smndaHs-Nd SrAnand1wrwn"[axe nml 9,sWl+.sAs dee hmdwtlr.sd owner,nPminrh.r.rmtof 6,,.......l 1x+1.1 al Lhc.Wll balyisia.ddrm,lU[rcLy autl,uriu Nes rder a <br /> any and Ill.t Ib mrd rtvfl*. W aaa.e+rnt iafi t m Itlla 1.SAN JOAQUIN COUNT I'L'"DNNIMTAL HEALTH DEPANTW"T sa soon a it ii a.ilable and at Eac asm[Nae It is <br /> Pmrided 4o m[ar nnrtPraualalie_ �Iy`_ <br /> APPLICANT NAME ' L'j�I J(�L� SIGNATURE ,r'✓• ,*, <br /> Tr" <br /> // J/jtP ]�_�D���[�1 DRIVERS LICENSEC��YYY"���"'��"' <br /> I• K. /!'T'J//t►'e/I� 'TA'�0��„� (rHOToccrrneuulRml _ <br /> Approvui BY -- UaLc�_ �hce :a,p Onioe Prtceairp LgraMed ev O.l. � (3 <br /> 79.!12 IOl{2107 MASTER FILE R,CORD GRIEF <br /> x1465 <br />