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Oct-08-01 12 : 36P M zK-��: n F> fJ� _03 <br /> 10/08/2001 11:00 20`3433 FIFTH FLO04R9GE 02 <br /> to/o8�0l MASTER FILE RECORD INFORMATioN "MFR" GREEN Form <br /> sw«om�tereraxFlin ORF �S�J4r"'�5�v: i w+7� M ,•+r,_. T����"'����� <br /> � r p <br /> . UNIT IV <br /> OWNER <br /> ar0MPL"-'n-',F0L10wVVGFROPLRTY OWNER.TNF0"Aa0,v.- <br /> PttgpattyOWNER PILE vY <br /> QV--Qr- OWNER Offlk nr0;Vf"lV7MEND <br /> NAHt GQ /ZPX l n e QV rn yL PWME <br /> - <br /> �3f M! q3f <br /> 6D tessNAME 5ririfia �e Pae,i�:c P�pel3wne �ar�r�exs, �.p t> SFPO 0,4 SMSECYT MD9 <br /> s�ii o4r r1l-o t� rS � <br /> Owner home Addrm <br /> ry1 1��O O wVl y� oruv�t�s Ltce�g <br /> City O q <br /> Qc'an � STATE C>4 � 92$6g <br /> 0-M M&T.9 Addr%,F <br /> lalling Addrew Cky stue zip <br /> MM FOwueaswro <br /> CatAotearapy❑ 1GaDrvcavu❑ ptwMAR,Sf. <br /> f�A[ere,r❑PACILOtMIR❑ <br /> _ IYY RILE <br /> r . _ <br /> M ' <br /> COMPLETFTNEl�LtUbt?N SINESS FACI[.ITY SITE INa x -� - x_ -�5 ,'� ���"" <br /> 770N; <br /> IS H1i5 a NE►r gtKl11tS6 Ltk'AT76N llot PIy rtfgtrlstod by tltfl I�fMIROtsAENip4 NEALTet DM51bh 7 Yrg �] NO ❑ <br /> Is tits an f�t,,atG l;ttslnt3ss�txwrmN but a NFvrTYre of nagu dated Business� Yea � �] <br /> BLXDdL s/FAQLrnf/5M NAME Na <br /> 5 FF? t, •S'. N sp— 5s fro f, <br /> siti<ADDRe55 <br /> L o wtsf <br /> surf%# Lxwess PNONs <br /> ?'o ne.s a orf <br /> �,v Noll STATS zm <br /> cAa.Y K <br /> Flailing Adpreyta/fQ 7PE/VTffvm fil6ft,6dd S <br /> Attention-or Care Of <br /> Flailing Address City <br /> STA- ZIP <br /> 9 Party� �fram Property r <br /> THIRD Pam BILLING INFO: Complete If Billing is rty Owtter a*Facility Operato kbnbffabom <br /> Btt +tEssNAME Ck A <br /> L)„ :�r s <br /> la�ing adt�t� e� 5 n LOA C� v e . S 14, ,�E5/p 25� Z`�Z � <br /> -7 z"9 `f 6 /Z <br /> J10- AJBr for fees and dtar9eg OWNER FAeILImsusmss THIRu PARTY BILLING <br />(,pJQr <br /> ((n }tLI.1NG AND f t1tNf'I.1?N .A KnQW'LlTY(MFN7: 1,tM andcrsigeed Applicant wtiry that 1 am the Owner,Operamr,or AM*&gwd Agem of this But mir am I ac <br /> le r'tT'a1nM,FNrMC� F1ffC-'IAW"RmdVorXWUYCN,ut.�a M++owkdgctAataRPExNrrFl3As, <br /> r ansoctated With thq operation will he billld W me at tbt addreu identified Rbow aS the.4rcUL M'ADDRSiS for fids aka 1 also certify Mad add <br /> OX afarmatton provided on this applleatton is ttw and oorrcct;and teat all r 71dascd aetivitiet WM be performod In accordant with all Applkable SAN JoAoucl Couxry Ordinance Cadh a <br /> :mala Lh sad Sr--and/or FCD[RAL Laws Ona ltesolab— As the undcrsignd owner,npernsor,or agrM Web.property 100ated at rite abort facilitylSlte address.t Denby awthorb¢doe Mrade of <br /> �ox Aly and an result+awl rnviroamentad ux=$fnent fafbrmadon to SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DIVISI <br /> se or my reprexentative- PLFAXPRM ON as soon m ie i."3'"3'141cta <br /> fsad at the see Time it is provided to <br /> r� <br />�Q APPLICANT NAME OMRS bIGNATUIUtE krV <br /> zoot1. <br /> Tlrtl V o.Q r I- a l d est ' rn tliti AIams LICEM <br /> _. <br /> (p►ttrtoctpy rtEQu <br />