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09/26/05 16:05 FAX 650552901 ERLER AND KALINOWSKI INC U002/003 <br /> San Joaquin County Environmental Health Department <br /> GREEN FORM <br /> DATE uj MASTER FILE RECORD INFORMATiOM "MFR" <br /> r# Ntb I c�.o 1 UNIT IV <br /> nau—MNIAME <br /> ENG '1 P O NE OWNER FILE <br /> R jNFORMATOW Ciawy OWNER(,IarlfEmyho,,FII£wme EMD <br /> i_vClrt / pItIX/B (.2oq) a82. _0ISb <br /> � Flet Id/ fast <br /> l` 1 '� SOCS-C/TMTD# <br /> `-' Dluvet51scx5E 7f <br /> S ATE 2m <br /> Giy <br /> Dwmer MaifinOAddraw SCi <br /> Mailing Addmn Gty ` ,� s"da CA <br /> LP qS 330 <br /> �enw.iso_atm ,/ <br /> conewuTra+EJ u+owmlu❑ PARTnE1 FEoaOEncr❑ omm[3 <br /> FACILITY FILE <br /> �Eaa y �a <br /> tt eI aT r "4 r2 tlgaoeif I§LSCiOi,dJr' i' le 11{ ,�vex kit", <br /> ✓ <br /> IeAr�Lm'11TIPia e � e �. w� >rk+`, Ddu"�' rflh tY <br /> ., <br /> MPL £FOL QW—MG BIJSSL'IESS.LF N R <br /> Is this a NEW BusineSS LOCATION not previously regulated 6y the ENVIRONMENTAL HEALTH DEPARTMENT? yes DNo Iffi - <br /> ... ..Is thiS.an.EUSICNG pusin¢$s,LOCATION buta NEW TYPE Of f0gulated BDSMOSS? ...._..YEA.Wt No �. .. ... . ............ <br /> BMNSS/FAm /Sag NAM' RPh`. CIe.A4 Wcr.�a'f ZOh% -A D <br /> $na AbonEde IS34O or.A 153(oo Me k:n lC AJC. Surto# BBDNrESPlwxr <br /> �.+�- afto sATsC� ffi 953 0 <br /> r I£Yz , <br /> BOaRDOF$Uph'PYLsoRQaimtef t e .. <br /> I tle:n�{ryrZ�gyJi .Rq'I! <br /> Mailing Address NOLFFERfNrYmLn IjdWAddress Attelhbn:or Cam a(opNonAlJ <br /> Mailing Address tSty 1�p D STATE ZAP <br /> STGCaOE T1T19T LYSE' APN$_I:1 -I / <br /> THIRD PARTY BILLING INFO: Cori/f Billing Party is different from Pro party Own eror FFael Ilty Operator above. <br /> p <br /> BuerNEss NAME C er p_ <br /> T K�1 <br /> Ma ling Address 3Ct0 C✓ � �j�,/,L QJ"II �� PHONE /�� g41/��t5,� Z) <br /> pry 1 t <br /> STAT" l/In• 2- -IS3�13 L� <br /> "=11 I1 Ars for fees and charges OWNER FACILI15TYISANESS IH THIRn PARTY BILLING <br /> A Rxna2 enrn.aA'c L dee undersigned AppEnnb cerfify that i em the(Iwneq Operamy or Au@rxued Agenr of This Bulinus,and 1 admawledge mer all rensur PEEN, <br /> PENALVES,ENFORCoNENTCHARM and/Or ROVHAr CfYARO£8 associated with Has operation will be billed to me at the address Identified above u the AXQUXEAnnaM'e foe this site.1 nb be certify that <br /> All informahon provided on the eppfudon u true and ciarroom and that RD regulated acdvltlu Will be performed in Recordmce WDh all eppikable SAN JOA um COUNTY Ordinonee Codes And/or <br /> Standards and STATS and/or Fximan L Lmve and Regedatiessi Aa the,mdersigued owner,operator,or Agent of the property loeazd at the above ne ity/ate saltiness,I hereby Authorize,the ream.of <br /> reornament Information to SAN JOAQUIN COUNTY LNVIRONMENTAI,HEALTH DEPARTMENT As scan as It is Available and at the some time it is <br /> uny and all aulte ad environmental <br /> provided to me or my reprmenmeve' ` PLEABE P�+T 1 I <br /> SIGNATURE <br /> APPLICANT NAME C rap 0't2A4 <br /> TITLE DRIVER'S LICENSE# <br /> Col\wj*n1 Fnq 1nQ(f (PIIDTDMPYtaEpeatrDl <br /> Data <br /> ^ D 0 01111iE pro cessi g completed By Data /3.j((7 <br /> eAPP ved BY 29-02-002 April25,2B03 <br /> CONFIDENTIAL <br />