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s <br /> San Joaquin County Environmental Health Department <br /> DATEGREEN FORM <br /> MASTER FILE RECORD INFORMATION "MFR" <br /> SHADED ARFAB FOR EHD 4B NL OWNER IDN p LZ O h 2 CASE 0 <br /> UNIT IV <br /> U OWNER FILE <br /> COMPLETE THE FOLLOWING PROPERTY OWNER INFORMA770N: CHiFaKiF OWNER CURREA7LYOAlflLEwrrH EHO <br /> PRaPEFM Ovmfft NAME ;--- I U rT PHONE (20q <br /> �9 <br /> First Mf Last <br /> BUSINESS NAME <br /> Cary O ,CDDI sDc 3Ecr TAXlDN <br /> Owner Home Address 22/ A),6�5r- /4%4F -57-te&-2F-I- DRN 9LICENsEN <br /> city Lcol, CA 15-2-110 STATE C4 Zo gSZ�U <br /> Owner Mailkg Address 221 W6:57— i*d�- <br /> Melling Address City Z U A Z O <br /> CORPORATMP4 0 INDIVIDUAL❑ PARTNERSHIP© Ffa AGeNCY❑ OTHER <br /> FACILITY FILE <br /> =F,,,L- ^ 10 1-1� CRg99 FIEF IDN - - ACCOUNT 10 '/\/� `{1) Q <br /> ComPLETErHEFoaoww BUSINESSI FACILITYI SITE INFoRMAnow �15L{AVIV\U J[ 11`11 y'l-i <br /> Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPT.? YES © No <br /> Is this an ExiSTING Business LOCATION but a/NEW TYPE of regulated Business? }' �G YES NO <br /> BUSINEsafFACILITYISETE NAME <br /> SiTEADDREss lam' y /, +++��C•••�[O py l� �Q dl SUITEa Busmrss PHONE <br /> CITY ^�/ STATE��/1n IIP <br /> BOARDOFSUPevlsoRDISTRICT LocAnONCODE KeM KEv2 'f <br /> Mailing Address KDIFEERENThwnFadNtyAd&v" �Y ��`r •'•'•"i ntlon:or&Care (opHana/f <br /> 77 RjerE tp wgr~n1 i <br /> Mailing Address City M��I� `rd TE *!S 'V7 <br /> SICCgoE <br /> [APN N�SS_ Q COMMENT; <br /> Tmma PARTY iOiLLiNG INFO. Complete if Billing Party is different from Property Owner or Facility Operator identifredabove. <br /> Busmess NAME ��,� �� ���/ Attentlom.orCere Of(upLFwW) <br /> FMingAddrepaMu PtoHONE q7 / ,gr <br /> CITY z' F6 2-Tmay <br /> AegaigWrAtMRESS for fees and chargee OWNER FACILITY/BUSINESS THIRD PARTY BILLING <br /> Hit.10ND.VNU COMPLIANCE ACNM11I11t LLnG,HRf41: I,[he uudenikiwd Applicant,certify that 1 ata the Owner.Operator,or:lrrlhdritivl:Igrnt of this Hnsiatsx,and I acknowledge that all 11f.91fir ftt.%. <br /> Pts u.ruts.Est elate uc�r Crraxucy andlor Nat a1.I Cu marc associami,,%lilt this operation still he billed to meal the atldrnws identified abdve as the.icy m%rliviRi ss for This site- 1 alsu certify thnt <br /> all inrurrnathut pros ided on Ibis application Is true and correct:and that all regulated actinides Bill he ptrfvrmed in accurdunce with all appllcuble S,k.%Jo vt IN O It,r!'OrdinBticC Codes antb'ur <br /> Staodtrrds and S I.%I F,anrlfar f F.uFN.lt,Lave and Regulations. As the undenikncd owner,operator•or agtnt ur the property located at the AIM foci "e adders,. he a rojenst,of <br /> any and all rtsukfs 41101 cnsironnICHI i LIMASnitnt information to SAN JUAQliIN COUNTY ENYIRr3✓•M12%TAL 11F:At:f11 DEPAR'f�l' s su as it U a au !I. <br /> provided to me or m}represenlaflfe_ <br /> APPLICANT NAME Q y MN &NG• PLEASE PRINT SIGNATURE <br /> -?Y— <br /> TITLE ! Ma,Pl�,v (rte I^�! �A�p ` OrtIVER'S LICENSE <br /> •G�-+-YGL? ../LY'C W PHOTOCOPY RE UIR <br /> Appewed By Data Accounting Offlao Preceseing Compidted By <br /> 19-03 10;1'�iI' \i��5I1.R ISLE RLQ URO-(.�RI:f:N <br />