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fMay 19 05 10: 09a P• 1 <br /> • SAN JOAwN COUNTY ENVIRONMENTAL HEALTN DEPARTMENT <br /> MASTERFIILE/'REcORD INFORMATION FORM <br /> S)MOEOa=xsFCRENOUwOse.Y OVrtMIDSy IU077 CE 10 <br /> OWNER FILE <br /> COMPLETETHEFoUOMNGBUSINess WNER/NFGNwAn N' 1F OWN ER CURREttYLYONMEW)TH <br /> BUSI*�ae —� F- U L`EY PHOF�NE�� r[ p <br /> OWaNER NAME fen NI Lear 9'0 -3S -0900 <br /> BUSINESS NAM Ey omrarKnomtswnarNMne) Svc See wTaK ID$ <br /> (�AR1;7-r a. S4 -0q-r/a 73/ <br /> OWNER HOME ADDRESS S61(o MDN td M9f e h lf, <br /> CITY j F§-yy0 O �. STATE Z P <br /> OWNER Nl7NO Ao0Rlp l dite�TNa*OmwAdd v=) rrmanan e.r,..et <br /> . 0 , 30X ;?--7.),0S <br /> MAwNG AOOMSS CRY <br /> TYPE OP OWPettsmr <br /> GORPomno,, WOMnu6L❑ PARmEm"Cl LOCH.Aaemy❑ COUNTYAGENCYO STATEAGENCr❑ FWAGEWYE3 ❑ <br /> FACILITY FILE <br /> FALILHY ID N: CO.OwNm 10 Y: ACCOUNT ID f!: 1727 <br /> ONPLETE TNEFOLLOw1NG BUSINESS FACILITY INF ATI N: O <br /> Is tl+h:a NEw Bohinew LD nom of VEHICLE not Pn:viowN reVLalmd by the ENVNL OUSAW HE V DEPARTMENT7 YFs ❑ No IK <br /> Is th'o an Ew G Business LCCATKA but a NEW TYPE ortegulotnd Buse e"? YEs ❑ No <br /> FFAGLrrY <br /> ITY NAME Mm sfs be o,ea--mueen ale HEALTH PERMm <br /> s prFe=ra a Moe SF*00 LWw Foxe vga0u=use"CCAUSSAWYA01 2MV Busamess PHOPS <br /> . 1 d�1x 9»n1 l�oitl�N !hh -q9,t- 800 <br /> aftf t WWrorPowVlroneuseme� • n,^+ ST ZP 3tILS6OGlnwCODE KEY1 KEY2 for NeaNh Permi&OIFFEREWasm f4abvAd*W ALMIEd1 orCa mO/ <br /> R HUNG AMR CITY STATE Zr <br /> 91C CobE A►Nn: Gam1 . <br /> d rrnHATT ennncee frf fees and charges: OWNER ❑ FACILITfBusmess <br /> g rl Awn ersnv r�rmmT f, the undersigned Appliant,unify that Ie/am the Owno Operator,or Aalhorked Agew this <br /> Business.and I acknowledge that all FFRHrr FFEr,p6VALTl=,PNFY)RCr.MYNr CMARGM and/or(HOURLY ClLNRGN9`assotaaRn wlm this Operanea win he <br /> ..L-.JA W. f-d.1.....oe the ArMfI Aovjuw fartTt,his si+ I also oertifv that 1alll in�formadohu provided on t"apTtl cation is true <br /> _ _.UGM �(Gy A-YAAI A'/ / ��y���S� <br /> G!/ <br /> emu <br /> jF L 55 <br /> 1 , <br />