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San Joaquin County Environmental Health Department <br /> DATE MASTER FILE RECORD INFORMATION "MFR" GREEN FORM <br /> LLLL���POSr7 UNIT IV <br /> FOAflC1V FOn EHD W-ON O <br /> LY ♦YNEA IDC CASES <br /> OWNER FILE <br /> COMPLETE 7NEFOLLOWNGPROPERTY OWNER/NFORMATIDAL' -CWEON/F OWNER Cl RFMTLYOXftLEWmr EHD <br /> PROPS OWNERNANE pKoNE LAf_35S/3(jS_I <br /> Fiuf M, Lest <br /> SUBINFSBNAME I,)fta Soc SECITA%If <br /> OWMBTNornE AddrOBA .10OOO DmuWs LICENSE: <br /> C4 STATE A/L Zip 3 <br /> OYrtnr MoIIMRAddmaa /c.K!/a'I�+� /�. <br /> Mail Ing Address Gly SdFe Zip <br /> GOAPORAi1DNIL hOMd1At❑ PARINENBHIP❑ FECADENCY❑ ZEAL] <br /> l FAGLnY FILE gyp^ <br /> FACIDTY IDY CBDBB REF IDRACCOUNT IDR INYR c f� 5 <br /> COMPLETE nfEFotLow/NG BUSINESS I FACILITY I SITE/NFoRMa num- <br /> Is flus a NEW Business LDCATICN not previously regulated by the ENViRDNNENTAL HEALTH DEPr.? Yes 1� No ❑ <br /> Is this an FROSTING Bu61nan LoCATIoN but a NEW TYPE Of regulated Business? Yes ❑ No ❑ <br /> j <br /> 4 ilhlt otvb SIYcw�a SUfiINFESIFACILITYI$nE NAMF. <br /> 6rrEAoosEas// /i�.I /y�Q /.1 6utrtR BUBiNESBPNON[ ' <br /> COY yam/ �! � A G17� iY STATE 44. <br /> z'p Y5337 <br /> BDA"OOFFSSUPERIASORD1uTA1Dr O LC(:ATIDNCOpE KED'/ 1{1Y2 <br /> M a I I h a Addrrraa IfO1PFERAWf.PaClRlyAddraw Attention:or Can Of fop&.1) <br /> MRIIkg Address CRy STATE zw <br /> SICCOOE MNR2cj '�C2/ _O� COMMEM: <br /> THIRD PARTY BILLING INFO: Complete ifBilliling Party is different from Property Owner orFacility Operator ldent4ledabove. <br /> BUVNEw NAME AtllrISWorCam G(f1 / <br /> le; l L <br /> MRlli,a AdMese /DO PNGNE <br /> Gm IYzAC.i n�sraTe LP �b <br /> torten end Charges OWNER FACIIJTTIBuswE66 L THIRD PARTY BILLWG <br /> art u mc:Ago Qwj,u Nur AETINIOYIFa:MENF. 1,the undrnignMl APP6ue4 m tify dui I am rbr Or.no,p1.crPar,or Audrorb adAAY>u of eda tiluinnv,arW i se4nowledye Nat aB P£annnTF2<, <br /> l£NA(.1]PS,ENFDRrFA)FWT CH.1HrLt3 Yndiar HOU.V.1'f.R.1Ffi63 L[WCia4A w1111 ds6 npw4ln wIS GE ItiRal b mr al Nc Addrm idarERtd a6eYG BS W2AGLYMATA/raFLCf for Ihil uta 1 Alu1 cnppfy Ilur <br /> all ivfarnutira P.s J d oP ttw OPir4odva a true sod.p I;uvd dut All reEubrd neNvidn wiB be perfannpi m acruH.with nI apptioblc SAN JOAQWN CDUMY Onliaanm Cuda and/or <br /> Smulxrda and STATE anWw pEuM taws awl RrJatiuns As ON,nndw3IViowner,aPerau,r,ur"Ewof dm yraprny 1.1w a<dro shavefadsry/sibeddrna,Ibcretry autl... arercJnssof <br /> any and all.,1"sod M..W.as A rat infp.N.a W SAN,IOAQUIN COUPnT ENVIRONMENTAL HEALTH DEPARTMRNT As won as it h avaibMr aed at tlrt avpe time it s <br /> prov cdto=ar Aryrcprl 06ya ,/ __-- <br /> APPLICANTNAME ?Y P Mtn SIGNATURE � A"ne <br /> TITLE / I /ya� DRIVER'SLJCENSEY <br /> (•/� PH T PYR UIRm <br /> Approvetl DY Gab Aeooun:in ORim ProeminO Cps MLd 9y Gab <br /> 29_(12 10/12/07 MASTER.FILE RECORD GRElt6 <br />