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a 0 <br /> San Joaquin County Environmental Health Department <br /> DATE MASTER FILE RECORD INFORMATION "MFR" GREEN FORM <br /> oYrNrRID# /5-/ s CASE x UNIT IV <br /> OWNER FILE <br /> commEJE 771EFOL4911M PROPERTY OWN ER IRFORNA7zom Oreary OWNER cueacmaravra taw END <br /> CC-S5- LLC Pno-t 31 <br /> FfW tt Last <br /> BusNa�NAtt LLf/. T-�,o ftl4S SocScc/� - 01&0 <br /> Dwrter Fiume Address Dnmutls LI(alSEx ` ` <br /> City STATE ffi IV <br /> Ovoner Malft AdMea t n '..) llr ULN I AP <br /> MaiiiaG Addresa City st-w C6 1zlP 3 z <br /> CawowsraN l7 DaOEVIDuuQ PaRTxea3 Ian A6eN.YO (Txea❑ <br /> FACILITY FILE <br /> FAnt W# 1pty`>Q CRMFEFIDx A¢wlD9 - 2�C�"7 Drv* s <br /> Is this a NEW BusilessUUL IOuJTION1notprevlously regulated by the&MAGNMENTAL HEALTH DEPARTMENT?J ,Yrs ❑ No a� <br /> IS this an EwsnNG Business LOGnON but NEW Trp!of requiajad Business? pp�w� Yrs ❑ No <br /> SMOSa/FA /Satzmam 1 Vf <br /> Sm Awsrss M <br /> tQ,l�1 -T r i1 sum At Busvesa Mani <br /> C[iY �(�t�� l� W StAIE 21P <br /> CA- <br /> Bo,uutU5LFERVS0aD1STX7 LMTWNcwe KEYS ICEYL <br /> Mairitg Address JfPVffRMVrfiom F d1fiYAd&twt Amntion:a Care of(opbbtW) <br /> Maifap Address CitY SYA Z <br /> sic CM! 140 <br /> THIRD PARTY BILLJNO INFO! ComPIefe if Billing Party rs di(ferentfmm Property Owner or Facility Operator(denied ague. <br /> BO511Ra9NNNE AttRnNOn:arcate Of(opbliw l) <br /> Malang Address <O 1. E 1"l ��/JlJ/^ ��Z'3 <br /> v - ti STA <br /> aAm u�for fees and aaW OWNER FACUTY/BU8INESS C S HIRD PARTY&LUNG r <br /> EL_.._Irruv AretrausxnrnreNr 1,tae andmigmd Applkaa4 WRY Mat l am ft 0"a,Dprylor,"AnfiarjtmAgee bBuaLa.x,andlaclmawkdge lharW PEaaartxas, <br /> ParvALner,Ervtwsflrma'Otatccsaallor HQum.z CHATx.'£-s alaadaled mottle tldaapenttanwiQ be hiBM mme at tlro addaw idmefied about as the "'&ia dtE lobo eeTtify flat <br /> all Information presided on dda application 4 trot sad cor t;and Met all regulated acdvilita will ba performed in ac Wtd..a with dl applluble SAN JOAQUM COUM Ordiamw Cad.aad/m <br /> Stam.&and SrcrEallam <br /> avd/or FKD6RAt.Lana and Regtdatbua. A+Me uaduelgxd owner,opemm�ar agent of Me Property latamd at Me ebaYe "tylaik addr.h exas oreenleneof <br /> nd ratan and eontwaaaafal�pT avant ha to JOAQIILY� T��ONN'MyF�.NTAL ILBALTD DEPARSM <br /> any aani nal t N utheme @na a k <br /> provldedrome ar my apraeaatiss , /C� {�y 04SPaM �f c4dL <br /> APPLICANTNAME CQ. LC.G �S CO'IT f`�ti'CIH"1'TY� SIGNATURE <br /> JD <br /> TlTtie V17e �'nFuNmEPIx <br /> L M--d ay +� Dat, Acmu WoffiO Pramed.o Can9i"BY -I Dau <br /> 7,4-02-002 Apd125,2003 <br /> CONFIDENTIAL <br />