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r. ? SAN JOAQUIN COUNTY + FlUef-IC HI-AI-TH SERVICES + LNVIRONUENTAL HEALT11 DIVISION <br /> FORM tE9400.144Nlwa0.0 tWU141 <br /> DATE &IASTERFILI- RECORD INFORMATION <br /> O"UR FILE <br /> COAf_PL_ETETHE_ FOLL0W11VG8U31NE33 OWNER IwomfATION: a sOx"` CwNaR [Srw+evrtrap*r+tCwrn•�lio <br /> Btmudas Qwr�t �—• � --- F-1 <br /> Bwe+.eaa Nwue(lf dlller�o�rFortrOwn+rTl�n+1 30C dW ITAX 106 <br />�. i gw►rtn Floes Aaoaess 4` . <br /> C:ly 1 aTr Tt: ZW <br /> Ctiv+ERYA:UwnAaOr+tea ffOfffEftEHT4n>hOw..rAddrrw A!lsrtltwr:nrCsnsal (updonsr) <br /> f <br /> Mailing Address City 7jp <br /> Tree or Owr rR8 rf- f <br /> CanraRAnON❑ IHUIVIOUAL❑ FAR'RiEMNIr❑ LocAL AGENC r❑ COUN Y AOCHCY Q STATL'AGemcY Q Feo AGENCY Q t?niER❑ <br /> FACILITY FILE <br /> �FAorEirr�fi3'>�-� ••�'•C>ao�s:Rer.=IC1'i1f1€l <br /> COItIPLETF TNEFOLLOWlNG BUSINESS FACILITY INFORMA770M <br /> 13 <br /> t3 this a New Suainess LocATro++or Ven1Ct:.not previously regulated by the YES Cl Na <br /> No <br /> Is lhla an Evwnma 8usinase LocATtort but a Newv T1rre&raguis4ed Htisinass 7 Y 13Q <br /> 9ua:r.e a e/FAcvJtY MALe(7+re mar.ae 7t+4ldar:e ort HEAT-'17!9'EltMdT I � --- <br /> FACCU"Anowess( AACKcMVWA,lRasrxf:ooatr <br /> awra Awa V&a=9e 121 1 autos 1 aurotuP4.w.t <br /> . !1 <br /> f CrrrrfFwculrrt*AAoaadfomt4rramfow ft"=xuWGQMMUWXA==&QWsTa� fit• <br /> ro:•:•:::: :r ..�:ar.:r.::::r::glEf 1( Yt:^»i Cf1Y2 IF <br /> Mailing <br /> i801111�0i13f�tV1ODN�16in1f2=': °tr'OdATtbN�17�C's:. i •: -•:F: � <br /> Mailing Addrvabs,farF(waiMP*mn YOIPFSMff vm.'&&W4,Addresa Alltealkm.or cam Of(apdarud) <br /> I <br /> d#alllnp Address City 9Tat1- � 1 <br /> t`SIC Gone:;Bi M: <br /> THIRD PARTY f3et.l.Ittt� INFORMATION-- Carp /i9l'u y oillin Pa !s dlfi?rs�raritfrt Busdra!aaa Owner/dar9llfled�hava_ <br /> 8iwr.+eaa Naaf - _ • A00"UM:arCAM Of MPd MMA <br /> i <br /> Mailing Addraaw <br /> r. <br /> Ore Lr <br /> etCCG7VNr_daamE33 far fees and charges (:)wN ❑ FACtL3tY(ISLIBiIMEt3S ❑ THIRD P1tR1Y 811.LJ> C) <br /> IIILL1140- AKr3 COhfPLIANCE AC TOWt.anet m rr. T, Ilia undo Signed Appifcant,ecrtlf'y 11118t I ua the Owtrer. Operator, or Authorized <br /> Agent o€ thin Buyine3s, and I acflnowledlle (flat: all pr+trr Feu, P:NAt.37 , &NFoRczurlYr CIURCE7 tndUar 4ffouR4r C1LiROU <br /> assecinted with this oper2don will be billed to ma at ilia addimut identified above R1 the CCDU.VT.4DARfor this Air- I 2190 [erllry <br /> tlrat all information provided on this 2pg1icati0n In true and correct; anti thaE ail rcCul2led sctivitles will be per-formed in <br /> accordance with nil applicable SALT JOAQutN COUNTY Ordinance Codes antilor Standards and STATE and/or FLrDr-ItAL Laws and <br /> Rcgufntlonx_ - <br /> Ptewas Pana <br /> $14NA71URE _. <br /> APPLICANT NAME <br /> i <br /> 0filv£R•8l_iaEl�ad?• <br /> TITLE IMIDloco"INE0 aeo <br /> Ips <br /> N;77 ' - <br /> s°A ro..,LiI .::::::....................... ::;:.:::iii°E9 f? ?i�hSgs{nfln¢;ffcRP.rvrllrs�.lRa.�t9t!}lL._ Y2Ec:�eSiE :c: :: <br /> ::QAifli:'i iii iiic �iiiii'i'i= <br /> pP... . ....Y..:............................. ... <br /> ................... ........1... .. ... <br />