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NOV/08/2007/THU 02: 58 PM P, 002 <br /> 11/08/?007 14 : 17 FAX 0002/002 <br /> San Joaquin County Environmental Health Department <br /> /y <br /> Are ( i D MASTER FELE RECORD INFORMATION "MFR" GREEN FORM <br /> OwaeaIDM IS3 lr CAaea UNIT IV <br /> OWNER FILM <br /> 0MP4E7F7NFF0I4ON?N6PR P NFORMATION: drero OWNER yvraexrrrD.e llu rrm END <br /> PADI2ATf O.FRN. pPtOPte <br /> n/ay NI Last <br /> gll5dF5f Nine sOCS[C/TAx ID F <br /> OarteerHune Adder a,tlk � � 17euuat's lxtfR9E9 <br /> an ,� sa<C q5 0`y <br /> Dwnar Malling Address <br /> a. S <br /> Malling Addteff Cky stna IIP <br /> uP..naernrr❑ INorv3arAc� PAameIURo-13 rta aaertcv❑ pnaRO <br /> --"� FACILITY FILM <br /> F.cni.+3oa QIUU RerIDA AtmUM ID6 Ito' <br /> U th,s a No euslneea LOCATION not PlINIGusty regulated by the gNVIRONhIaNrALHEALTR DEPARTMENT? Vrs 0 No R <br /> Is thisan EATMUG auslnt IQGMN buta Nmv7VSE O>f regukM Buslneed;9 ossa ❑ Na R <br /> BUsnerss/fAewry/gee NANe l <br /> (, e HT <br /> Slee ADDeai �00SureeO gUSgie%RIDNIt <br /> O <br /> tart I'- STA m 6 <br /> aQUD OFSusrAv2mR Disra¢r LOGTWNCOOr IQe'1 KEY <br /> Melling Address NO7RERFMrAsn bbd1WA4*w _ AkmAtoni a, CAME Of'OPVb O <br /> 9-74 <br /> N till <br /> Mailing Addleis City IZ STAR <br /> sic woolAP.a A CdRi'drih3 <br /> THUD PARTY BILLING INTO: CL%`f7P/eteif Billing Party Is/d/fferentfmm Property Owner orleaclilty Operator idenb75edabove. <br /> 6URNrbYN,wc Att4nWA-WQre Of (q b;,;IWf0 <br /> r <br /> Ma11)11g AddeRn �, h 1 ✓ <br /> CnTStoLlckA> tT aPgs <br /> A=au&LAnnMee for}aes and d3atgea OWNER FACILITYBUSINESS THIRD PAITIY BILLING <br /> Rn.,ir,r..un rmm�,.n Arxxny,.enr.MPRr; f,meumenilned AppUcael,arWy thulam lne Owes,[>tbww,Or AulAnrked A,peN of RJP RWlnn3.aed LAeWwwldle Maf dl PrAefrr Floe, <br /> l+erucnu,fgNR M6ATGN.H.'rS angler/davatrrnAWr T aerodANdwith"operwrion will Ir•Nyed Nmeal IJand4ed abOv,As thedr+++r=4aa=Poe Otis eine. 1Weeertiry Mae <br /> All Infone alley prywd—My APPgtAhop O rive sod cAr 1,Atw Mar all Neulefat acdNde,,4 ee Perfomvd In Attetdaaoe with oil apPlkahtr SANJOAQNN CONrry Ordinate Codd aad/ur <br /> SondArdP aed 6'rA,e And/Ar 310eWe.Lavr And ReeuladoDa Ae Ne utatenlpad wraer,Pperatpr,or spat df rite D=,,eoy Inanrl at the above re Mljfeile add rosy 1 hereby Puthorfu me ritue a of <br /> iey aM W rmulu end eneiraemnnl Yeal ner"WOrmen®no SAN JOAQUIN COILW I'ENVIRONMENTAL NCALT14 pARTMt:M os In adY blit and al the wno onit It H <br /> Provided to me or my NPraedu&t, <br /> APPLICANT NAMF7—bj�� ��t P �P rt SIGNATURE - <br /> Trru J / `J/ f!"YER'S LICENSE H 1-AAAA i <br /> Aeerevea er D.m �� 11®fmDlq g}Ilea Aow>dng cemdemd <br /> BY <br /> 2602.002 Apn125,2003 rt <br />