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a 7-06-1998 4: 1AP-0 FROH P. 2 <br /> ME 0%RNKS(AM <br /> GREEN FORM <br /> DATE MASTER FILE RECORD INFORMATION "MFR" <br /> 2nWARIA rpq END a9a Onq UNIT IV <br /> �UJlAS-Sl0 OWNER FILE <br /> COMPLETE 7HEFOLLOW/NG PROPERTY OWNER INFORMA TION.' PAYMENT CHI OWNER CuRRf'gTGYONfAEWONEHO [] <br /> PRDVEIzry RECEIVED <br /> Tr' Co., PHONE / ^� <br /> OwuEa NeME rf aS Y W2-700 <br /> feel v ar <br /> SUSIPI NAME $tic SEc/TAF ID a <br /> SAN dOAOUIN COUNTY <br /> Owner Home Address3(� 7'Z D Lite,K C re eK 71�IVIRONMEq'r#L HE46H DIVISION <br /> !l � bI0t9 V DRIVERS LICENSE I! <br /> CityDI_-T-AI LI u0-i- 631A,LA r3L-.E— STATE Zip <br /> Owner Mailing Andreae <br /> Meiling Acidness City �}�Sy,(�-�.11/'Y Stale Zip QSz� ,6j <br /> CORPORATIONO INDIVIDUAI❑ PARTNERSHIP FEDAGENCYO OTHER0 <br /> RFACILITY FILE <br /> x (hWdE. dt 'r,T r,;pYxe II`e " ' 77777717If' tII ,,yr4R ht�r . <br /> fora l 9 a I'CROS ' 'r.l IT,/.i. +.n CDUN, <br /> COMPLETE THEFOLLOW/NG BUSINESS I FACILITY/SITE/NFORMA7TON.' <br /> Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DIVISION 7 YES p No <br /> Is this an EAIsnND Business LOCATION but a New TYPE of regulated Business 7 YES p NO <br /> BVsuiessIFAciurrISTE NAME <br /> SITE ADORM 3 6 3Z J yeJCn \ ^ SUITE B!UU-7ySINsTZ' <br /> Cin <br /> z5n>e-4---mrj STATE C4 rzZlPq - <br /> `1 J tl 4) II <br /> tt �sZ <br /> .n �.... .. ♦ ...... .a..d...It t14A.Lw��J. .._ � ._.4 ':V�O✓�rwV..n,... .. r.. <br /> Mailing Address i(DTFFER£NT)rm FaclllivAddress Attention:or Care Of(optional) <br /> 5:Avf-5 <br /> Mailing Address City STATE zip <br /> APWO kihr °n4. Iyi<;iv` L'i '�oAhM'Eeir " ori v' 4u n ,l�, dill Y V ta; <br />