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APR 2 S 1999 <br /> ,,, .;.t nrr��Y1 '�d� �@ iC25" �;,.;•.-"iw,torzl�3�#��tYtSJOII <br /> ; PORP (FH OD tSIREvoED Dalt1AT} <br /> Dar£ <br /> MASTER FILE RECORD INFORMATION <br /> > UNIT IV <br /> OWNER FILE <br /> COMPLETE THE FOLLOWING BUSINESS OWNER INFORMATION: CHEOXIF OWNER CURREA LYONMLEWTNEHO _ <br /> —�_— ---_ PRONE <br /> BUSINESS <br /> -- — _— <br /> -------------------: <br /> OWNERNAME -- wt Last <br /> _..._. Soc SEcl TAX ID• <br /> BUSINESS NAME(If different from Owner Name) <br /> OmwYs tdCENSEi <br /> OWNER HOME ADDRESS <br /> STATE i AP <br /> Cty <br /> O.ERMAjUNGAOORESS (WDIFFEREAIThvm OHrrerAddrwss) i AttentiorC orCars of(godD+d/ <br /> state ? Zip <br /> Mailing Address City <br /> CORPORATION❑ INOIVIDUALQ PARTNERSMp13 LOCAL AGENCTQ COUIT'AGENLTQ STATE AGENCY FED AGENCY C2 OTHER❑ <br /> FACILITY RLE <br /> 91.7777- K <br /> I. GAc�TiX.III ''•` ,�:.., ,g u :LxteissFa=tQ� _ ... ..... <br /> CO3sfPLE7E7-HEF0L1 OWING BUSINESS / FACILITY I SITE INFORMATION <br /> Is this a NEW Business LOCATION not IseeviotalY regulated by the ENVIRONMENTAL HEALTH DNISION 7 YES Q No Q <br /> YES C: NO Q <br /> Is this an EXISTING Business LOCATION testa NEW TYPE Of regulated Business 7 <br /> SUSINESS/FAauTf/SrTE NAME <br /> i SUITE III i BUSINESS PFOeE <br /> SITE ADDRESS <br /> STATE ZIP <br /> CITY yy <br /> Mailing Address if DIFFERENTfiwn Fa My Address Attention:or Car'Of(00760"230 <br /> STATE ZIP <br /> Mailing Address City <br /> 26 <br /> J <br /> —,.... <br /> THIRD PARTY BILLING INFORMATION: Complete if Billing Party &different from Business Owner (den Lt/ea above. <br /> .-- AttenCtxC orCare Of (aPdtinwO <br /> BUSINESS NAME <br /> PHONE <br /> Mailing Address <br /> STATE I Zip <br /> CITY <br /> ACGOUAITAOORES for fees and charges OWNER FAcury/BUSPIESS THIRD Parry SLUNG <br /> 9rLLINr AND COMPLtANOE>C>(NOSVLEDGMTM: <br /> Lit.o°denigned Appdats,c dfy dot I am the O' .Opernrar.Or.lanlaor¢rd Awes[of this Bis and I admowiedge that ill <br /> P>rxtnT FEP.R PEW.tGT7ES. EN`'OHtPAIEA'1'(7fARG7s and/or ROURLT Cf"= avotaLLd mth this °peratlon will be billed to me a[the addrel$ide°dited above as the AC.^OtMi' <br /> ADDRESS for this site. I also certify that information pmvided on.this appon is erne <br /> iicaaad vnetX ad that ad tewlrted wdritks wit be Performed wrdan¢mN all <br /> m x <br /> at ai <br /> SAN JOAQUIN CO <br /> assessment <br /> Applicable SAN JOAQUIN COUNTY Ordi.=—Cdes and ior.Standards and STATE aDdlw FEDERAL Laws ad Regulatiens. :u the udeesitmd owner ,opRalor,or agent of the pmN—Y <br /> locatd at the above fadgty/site ddress I hereby usbomw the release of any ad all � ad armm.mensal 'DformaGoe to I1YrY <br /> EYVII20rIwM,frAL HF,LTH DIVISION as soon as it n available ad a the s time a is provided to me or my mprvmutri, <br /> PLEASE PRINT <br /> APPLICANT NAME SIGNATURE - <br /> DRIVER'S LICENSE s _ <br /> TITLE <br /> i Apptaved$Itis.. a*rc Date: I Actmtesti<sg O@farProceetnFEoea*QfaedOi" -I7afr:: `::t <br />