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San Joaquin County Environmental Health Department <br /> DA.II 1 <br /> •i � b . MASTER FILE RECORD INFORMATION LiMFR" GREEN °ORM <br /> d � O <br /> 1 _ UNIT IV <br /> OWNER FILE <br /> COMPLE7F 7F/E/vU0w-TfyGP PERTY OMNER INFORMmyom _ Gfrchr F OWNER CYAArM)lYQYFIlEWI1N EHO <br /> PRDPanvown NA pig <br /> /f „ Late <br /> BMN, C4rc f(/N/ /O1 <br /> /1r¢ <br /> xll <br /> Owner Home Address 1-16, <br /> t �vovr cevj!�� $eCSC</TA%ID# <br /> DRNERSLsKENse# <br /> city ' STATE n N Z@ /Jz�I <br /> wer <br /> OnMailing Adelson; sJ C./ <br /> Mailing Address City JT'v`� Stile Zip <br /> ,wnawrorawa <br /> CORPoPATDNI❑ tsorvrDunL❑ PaRrxERStD FED AGENcr OIIEIt❑ <br /> FACILITY FILE <br /> EAIETfYID# )e,J ' (b/_. <br /> CROSS REBID# AgptlrNyjq,jf INv# � �v^,�5 C.) <br /> COMPLM 771EFO L ZS LY 4 may., y.n <br /> Is this a NEW Business LOCATroN not previously regulated by the ENWRONMENTAL HEALTH DEPARTMENT? Yes ❑ No ❑ <br /> Is this an EMS I NG Business LOCATION but a NEW TYK of regulated Business? y�_� �'�,.a����r.�Yes/❑vT y-�No ❑r-a�)��/�/ C L� <br /> BUSRa65/FAmITvISIrE HANE {TBR XA'9 /r-`e�- 5rr-'P (�pfA�( >C •✓/'Ty,rifr—� 4'61 T 0-CC� <br /> Cvi eeyoer- UVTIT-+� <br /> LirI L'rvC"r!it• SucIE# Btmrn�PlaNE <br /> Qry Slf/( (QwV SrATE/'/1 ZIP <br /> Mailing Ad(Ir ifDlF/EREwfI F,ti&ftyAd&r Attention: rar Care Of(optionaQ <br /> 6P No fLTdi/Lt o Csf ceyx—1 <br /> Mailing Address Chy '47VVOu� SrAT¢�-./, �p q•il'l�lrl� <br /> �1�" �p►v cep o` z C�/1- L9f-�L� <br /> THIRD PARTY BILLING INFO- COm(7/ere i1' BIIIIDg Paft)r is diffemnf/mm Property Owner or Facility Operator identified above. <br /> BLLLfESS NAME <br /> Mailirg Addr¢5�9T�wyfl�-�L/ /CTCf Cro 6Aj(j-t n,fy_Aot e�m tjc�Attention:erecting Of(OpflMnia?) <br /> 5 r1111 PNONE Geq 4-6 <br /> ._/00 <br /> CrY STATE /:,� TID7 pz <br /> ACC^.rAFAaoREcc for fees and charges OWNER FACILITYIBUSINESSTHIRD PART BBILLING <br /> )III.,ING ANNICO.IIJJANIgAl'"111ril rdl. 1,the undersigned Applicant,certify Wal I am the(Avner,Qecraar,or duMnowed Agent of this fbmnu, ell PFRN(TFEEP, <br /> PENALUES,Erctioacevcrvr Cnnxea andlor NOD/1/YfJUA(ES nswcimetl with this operation will be billed In meat We address Identified above as the AM)IRrrAnnnvice for W9 sffe.I also certify that <br /> all information provided on this applin.fn.is true and correct;and that all regulated aclividen will be performed in accordance with all applicable SAN IUAQIIM CnlmB Ordinance Codes and/or <br /> Stntdartls anJ STAB and/or PEDEML Laws and Raguhtions As the undersigned owner,opcnwr,or agent of the property located at We above fauey/Hite nddress,l hereby authodu the releaa of <br /> any atd w mulls aid enviromstrialtall msesemnt information m SAN JOAQUIN COUNTY NNVU1ONMENTAL HXALTH DEP ENT A nn9�-it�is available and at W same time it is <br /> .me <br /> provided APPUI ANI ormyrepr% t/Ie�ti1 E�7 <br /> APPLIGNT NAME �rASE PRIIrt f <br /> �s���"II L SIGN <br /> ATURE <br /> TITLE via- 'I/t N'y — C <br /> VW St� C DRIVERS LICENSE# <br /> (taamomPr aagutREof <br /> 6y DeR AavunBnp 011ina HPL¢dnR Wngkletl BY D— 7 <br /> 29-02-002 April 25,20M <br />