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09/26/05 16:06 FAX 6505529012 EWER AND KALINOWSKI INC 12003/003 <br /> 0 0 <br /> San Joaquin County Environmental Health Department <br /> GREEN FORM <br /> DATE MASTER FILE RECORD INFORMATION "MFRY' <br /> say <br /> 51ti...-manstagnuagO, UNIT IV <br /> OWNER FILE <br /> CompleTEYHEFOLLOWNGPIROPERTY OWNER Cwmv OWNER euaxeWrzrtwm.cwrrx EHD <br /> 7P�7�M�0-1�N-. CArq R— <br /> I Rnif M1 Last <br /> Bungles;N,ta 4 SOE;9EgC/TA)(ID# <br /> OagnserMorneAddragas <br /> CITY STATE ZE, 71 <br /> Owner MaIlImAddrass <br /> rm,,I,ng Addsiass City T„OState zip IE3.30 <br /> El brmv 13 pNtHeILam❑ FWAMNEYE] <br /> FACILFTY FILE <br /> A <br /> D a* <br /> FLAC�ID,.k- <br /> cQ—mPqETETHt-FouawxNs BUSINESS I FACTLITY I SITE TNFORMA770N. <br /> IS this a NEW HusthleSS LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? yEs No <br /> Is this an EMING Busilreas LocATION but a NEW TYPE of regulated Business? Yts El No <br /> WI <br /> stingo# Busmr9L.'?) <br /> CITY smInIg zO, q.,-3,,) <br /> 77 <br /> z] j[ EL <br /> Fki <br /> ..Mailing Add want, FadWAdcratea Atterstlogrues, Core Of(OPbbW <br /> Malring Address City STATI! zw <br /> P, i ai <br /> , <br /> 77777 7 1 <br /> LLM '25'�Wi .4. <br /> THIRD PARTY BILLING INFO: Complete If Billing Party /s d#rerent fmm Property Owner oi,Fadlity Operator 1cfentirled above. <br /> BUEEMESS NAME Attention:WCOAM Of (000MI) <br /> Melling Address; PIME <br /> STATE ZIP <br /> CrTY <br /> r�-d�.•n..wr A,.,,a¢R for fees and charges OWNER FACILITY/BUSINESS THIRD PARTY BILIJING <br /> I;The onlegraignets!Appikant,tartify'bat Iswa Ne 0m,operurw,,orAMIJivriond Agenr a this lgagiaoa..and I¢cwmntw,Net A <br /> with thisoperating,will to biW t...t thaitildligna Isisitisand above the ACT Poe this sifa ladso-stifyfli-t <br /> and that all rountanNI aollilfits will be performed in at"rdancewitil au.,plitable SAA JOAQUIN COUNTY Ordinance Codes soadifor <br /> Standards Ends STATE"nillin FEDEEEms,Liwaand Regulations.Aa the uMemigned owner,eperalor,ar agent of the property Wu'ed at the above fecilitylelte adtlnee,I hereby aamorve Nc rdeme of <br /> COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as goo.as it I,Available and at the some tion,it is <br /> Any And.11 .WN and goo,hostagatal--assonant itifinnoasli W SAN JOAQUIN <br /> p.Ad.dwinw.rinsyMnationsittAg- RE <br /> APPLICANT C. UMCZaVx SIGNATU <br /> TITLE a DRIVER'S LICENSE# <br /> =App--d BY logibe <br /> 2902-002 April 25,2003 <br /> ?-�-D <br />