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San Jtein County Environmental Health �artment <br /> DATE ;'1zs/G� MASTER FILrE� RECORD INFORMATION "MFR" G1REENFORM <br /> WN <br /> fftfA&CR�eFes_r4Rl'NQ usE ONiv OER ID# 'ul \V��510�o CABE# UN'T 'V <br /> W OWNER FILE <br /> COMFLI57FTHEFott0wb oPROPERTYOWNER/NFoRmwzom' cRECRYFOWNERCURRER YQR LFWTREHO <br /> PI�PEarrOwaet NAME PNoNE <br /> t r—EI Irt1' <br /> Flraf MI Last <br /> !"(-mus/iY� _>-4—GLfJ2S�orS ,�a � Soc SE TAx IDf�'' <br /> Owner Haase Address 2Qt �j n� JI . l Z.�� DRIVER'RLanitse# ,U,4 II <br /> City <br /> STATE <br /> Owner Mallln9 Address <br /> Mailing Address City � ,,,r v y'y�-qState t�- ZIP <br /> GORPCIRArKMIEI INDIVIDUAL 11 PaRTNisnoop FinAOENQr� G OTNERc] <br /> FACILITY FILE <br /> FACIUTYID.# Ffl�D� l�a� CROUREFID# AcQOUNTIOM 4�() S _q INV# <br /> ComxETf nfEFOUOVw1NG BUSINESS i FACILITY(SITE/NFORmA now <br /> lJt ,,,,�_,// <br /> IS this a NEW Business LOCATION notpreviously regulated by the ENVIRONMENTAL HEALTH DEPT.? Yes I� No ❑ <br /> IS this an EXISTING Business LOCATION but NEW TYPE Of regulated BUsinese? YES [ No ❑ <br /> BURINESWFACILRr/SIMNAME +11 <br /> /Y--^�Q/G..CS.NL-I 1AP�//' QX" <br /> SRE AQIME99 I �� E l l \.� _ .1 �../_ . SUITE# BUSINESSPHONE <br /> 44�� E�[J srr""cV66 44P»LL... 4 <br /> GnY �d) y\ STATE,-4 ZIP q,'�-2© <br /> BOARDQF 3UPEc1RNt)QR Dtsraltr:. LocATIONGooe Ker? KEY2 <br /> MaIRng Addreae BD1FFERENTrrom Facdky Address AUen' n:or Care Of topyona) <br /> f <br /> Mailft Addraaa City y STATE ZIP <br /> SIC CLIQE APN# COANaENT: <br /> THIRD PARTY BILLING INFO: Complete ifBilling Party is different from Property Owner orFacility Operator identified above. <br /> SUSINEss NAME � �� f�Lc7{IVlQ�(nl Ll `.- -v"Ut C 'S Attention:orCare Of topHonal)'F,I'r{�[ <br /> Mailing Addrasss N:]> 7 [r 66,<I, 6 <br /> CRY &Aftp— l STATE <4ZIP 9,1x L2O'\.Q/ <br /> ' <br /> dL17UyrAaoESfor tees and charges OWNER FACILITYIBUSINESS <br /> PARTY BILLING <br /> 811A ING AND Cmtn UYCE ACKROWIFM]AIENT: 1,the UnAcrsignM Applicant,certify Ihet 1 in.the Oanea Dis rono,ur ANlhorized.AtnR of this Susinen,and I aduatwiedge that all PERsin'FEeq <br /> PFYALms,f-s"jR,ENEEYICImR(mv and/or Rf)UR1TCNAR(IEr associated with this nyeration sill br billed to on,M the addrcvs identified above as in, LY'oLA'rAfIOREcrfor this site. 1 also cerci&that <br /> all information provided on this application is nue and e.,wt;and that all regulated acNvitics rill be performed in aceordanrc n'Uh all applicable SoN JOAQUI.N COIMI Or .lnon,re Codes antUar <br /> StanAardi and ST,It anNur 44DEML Lars and Regulations As she unAcrsignM onnmq operator,or agent of the prallem IncatM at theabov s�(IIL 1(E�a1'I I yl, raleaeof <br /> any Andell..Itsand ensimntnrond xsamoonst infrmefion to SAN JOAQUI,N COUNTI ENVIRONMENTAL HEALTH DEP:1IYf EW' s _h r' is )0d"N"uttinatitis <br /> prsrvidtd lomeornry repres,.witi d T ' <br /> APPLICANT NAME i )� d ) PC:± SIONATuftE K <br /> MILE ' I rrl v�LGI Q;( g.r^p.'�L dry S' �'jv(f� Q � DRIVER'S LICENSE# <br /> (PHOT000"REQU(REQ)' <br /> Appreved try Onte Accam1in901Rae Proo.-aVCompleted Ry Dab Ip <br /> 2•I-D2 11I112i119 M SIER I'ILE RECO D-GREEN <br />