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<br /> DATE 0 I v Z4 (�1� MASTER FILE RECORD..+INFORMATION
<br /> UNIT IV'
<br /> OWNER FILE
<br /> L),IECKIf OWNER CVWrEivrcr0,Vq EWT7+EHO
<br /> COjNPLETF7"HEFOLLOWWGBUSINESS OWNER INFORMATION- _, -•
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<br /> OWNER.NAMC � ——
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<br /> SUSiNGSS NAPE(If dOlarent fizm
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<br /> OWNER HotlE ADDRESS oa rER's ucsxsE a /s
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<br /> OWNER MAILING AADRE33 (if DIFFE)Z4NTfi•cnr Owi7iWAddnms) -
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<br /> ktailing Addrtsss C-tty S = Zip
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<br /> (.ORpoRATtON INOMGtAI-❑ PARTNMMP❑ LOCAL Asemcr❑ CoLWN AaCPCY 0 STATE AGENCY© FEv Ae•:Nt:r❑ OMER
<br /> FACILITY FILE
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<br /> ComPL6TETHEFOLL0WING BUSINESS/ FACtL"I SITE INFORmATION.
<br /> Is alis a New Suslneam La CATION not Prww'auxty cogulaLed by ttm EwAgammEwAL HEALTH OMSIDN? YES ❑ No �
<br /> Isthis an EXISTING Business LDr-aTION but NEW TYPE of regulated$tnslna= ym ❑ No ❑
<br /> $LISINE5SIFrtCtLRYiSIrE H/WE �+1 to 'E f f VP L� /Y�•
<br /> J wc`• /]�IIv 6 SIQres RusmEss PHONE
<br /> $ITE ADDRESS
<br /> ST CPr as '153-3
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<br /> Mailing Address ifDIFFERENTf-am F=FW Addrttss i At>Esr6Ota:Or Cara Of(0pffonXa7
<br /> mailing Address city STATE zip
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<br /> THIRD PARTY BILLING INFORDATIOW Complete if Billing Party is differS$7tfrom BUSineSS Owner IdentWed above_
<br /> SttStNESS NAME �'I � _l� /'""f”� AnenA1 Vin_a.-CareC�f0, -
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<br /> 1M f ng Address PHU
<br /> STATE ZIP
<br /> CIT, -. . .: . - CA4• '3
<br /> U w for fees and charges OWNER FAcamr INESS TMM PARTY B1 LlNG
<br /> SILL Q-:TIM COMZLLANt f..ACI4"r_t7tyL D 2t' I-the anderalteed Applicant certify tLar I am Use Owmzr Operator,orA&zhor ed A&mr ofttiis Rusio=4 and I sdman-ledge thsx rlt
<br /> pJtsrrt F rrz-,, 4P.,vAt7wS• Mv7VACFu PPrr t?rAA==d/or XOURLY C rL AGES aasomled with the operation wj4 be billed to mo a the address identified above as the C PLM
<br /> Ana �,cw fnr thin site- I also certify that all-snformadan pevrided on:this appUcadoo is true and sarrec:4 and dw adl regulated xtivitics ww be performed is mecca+dance with all
<br /> applicable SA",4 nm .JOAQULr COUNTY Ordinance Codes andforStandardx and STATE d/or FEDERAL Lzvs sod Regalatioac ,Xs the nadersiped,ager.opmeor,or agent or the pmperry
<br /> loeated at the above facility/site address~ I hereby wthoriae the reioase of Say sad all rerntts.and environmental asssssucut information to SAN 'JOAQUIN COUNTY
<br /> El,\mv ROY1$Zti-I.A.L fEELI,TH DIVLSIOrf as soon az It h available and air the samn time it is prwrided to me w�mprarntaRve. -
<br /> r. PLEA3>;PRINT.
<br /> APPLICANT NAME Jcr, FW- (AS L�y� r ��� IP S1G1dATI)RE
<br /> TITLE ' oRIvER'S LICENS
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