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8-25-1999 :0.9AM Gf-t n, P. 2 <br /> PLITT 41t <br /> r ._ <br /> GATE r <br /> GREENFORM <br /> MASTER FILE RECORD INFORMATION "MFR" <br /> SMAOEO AREA3F OR ENQVJEOKY ani UNIT <br /> 'V yi <br /> OWNER FILE <br /> COMPLETE 7HEFOLLOW/NG PROPERTY OWNER INFORMA7/ON: C/.6 1-' OWNER CuaaEwscre,V F/LE wFTFFEND <br /> PROPER <br /> iTYY �� �� <br /> 1I /� PrwNEZ <br /> �. OWNER NAME I }I o �vq •J L` <br /> BUSINESS NAME C �- G (U K'l.Lvll �� t SOC SEC I Tax ID 7! <br /> DWOef Home Address <br /> p�„S y / DRIVER'S LIC"SE 4t <br /> Cl5�' <br /> ty O✓YV� I l $TATEC H <br /> � O,vnar MWN„S AGr1.o0a / <br /> �CA <br /> Mailing Address City State Zip <br /> CORPORATION n INOIVIOUA4 F1 PARTNeRsIIIP FM AGENCY C1 DTHER <br /> CIS IA5zp FACILITY FILE <br /> -.;:x Y a s:t ti�Ipj�,��.. '•.'I• �. pERY'cYB3tR61f . . Amyl. NO 3•tda� <br /> _COMPLETE THEFOLLOW/NG BUSINESS /FACILITY/SITE INFORMATION: <br /> la This a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DIVISION? yes No <br /> F <br /> / VIsthman ExAgIn"O Business LocwnoN butn NEWTYPE Offegguu/lated B inese 7 Yes O NO <br /> BusiNess/FAC141TY/SITE NAME o I( iY IVV( I /\ -� <br /> � I, <br /> SITE Arooge/331 (� / I I� J� ,l. .SIUEUIITEE / BUSINESS PHON -\ <br /> ' �I�t`�F 7f1 WIYl OI IA/r/JI 4� �I •JV' ��M / II/IGd4�, � / ��I r]YiVI �I ✓L�(i IAC/ Ll7 u-t✓lIV�17IGIM ('Nk{!1 <br /> CITY STATE d j ZIP <br /> qS � rrr"'999 <br /> ^ +L- <br /> L�QARPOFIjtIPERVIBOR,- �.�:u_ _.._1�.Y,�ra� ?� F:_.J�L ,..�_.1::K6y? -[�' '•i mu i_x�\ I,. Y� 4 <br /> ••.••• • .•_...yi�.� -`LY ~il Mn:,\r.lq PIN4 :u_.v may.�,J� <br /> Meiling A dress i/D/,FfFERENTIrom Facility AOCreea Attention: or Care Of(opf/ona/J <br /> 4FrtYLf/M � -5l7 A) r� �yac�D 5F• � [a �jvalt�� <br /> Mailing Address City PG/ STATE(In Zip �D <br /> I •�.TLIn � /'i <br /> :SIC CoUe (. ' y � •-� �� i .f �--ar^--.Ind-+^f, rn� —i r t,.;:, <br /> T <br /> s II <br /> THIRD PARTY BILLING INFO; COMPlete if Billing Party /sdATerentfrom Property Owner or Facility Operator/dentifledabove. <br /> Bu61nE3s NAME Attention: or Care Of fopt/onaq <br /> Mailing Address <br /> PHONE <br /> CITY <br /> STATE Zip <br /> ACCOVNr DORESs for fees and ChargesOWNER FACILITY/EUSINESs THIRD PARTY BILLING <br /> &u,INE;Avn CuMr4uNGE AC1r;lOWLEDCNENT: L the andenigncd Appliein4 certify that lam the O WRU,npumrFr,or Aatfron:cdAgmt of Nu Baainess.And 1 acknowledge that ail <br /> Pt'RN?J2Cr,Pg.'ALT/CT,EvPDRCCNBYT CFLVtfat and/or HOMY CHAR441 assumlel witb this opMtion will be bill d In we at the addrue me,tihd above As IheAU.Vt'NTADDRrST <br /> for this site I RW certify that all information provded on this APpliotion is truA and correct:and that All regulated Activities will be Mformad in acrosdance with all applialb c S,,v <br /> JOAQUIN CoVN Ordinance Codes na llor Standards and ST.ETt and/or Flub A L LaWe and Rqulalio" As tlK WdcrAgnod owner•aperanr•or Agent of the property IOaIM At the <br />'above fic ll"Isite AddreIA, I hereby and oe6,,the rekswe of Any And W result, and cnvtronve tat a+sesemeat Information to SAN JO.AQUIN COUNfY E.YVIRONNE`1T.U. <br /> REAL Ill DIVISION as soon r it u AV Aihlb1c and At the same lime it h provided so me or my repreteabuive <br /> P12!A3E PRINT <br /> APPLICANT NAME ��/-� j �/�,L- SIGNATURE l�A/ /I /l <br /> TITLE ��/��/ � �I DRIVER'S LICENSE 0 AVL/�I/ <br /> (� /...oTocorY Rrouwrnl <br /> APpr�m.e4 W,+n�. ~w":y'�NYDa .. �a�. ' ol.:'' -^ -A ,rob;.;ciNi`.:ti�'1,. �Sn'e'r^a'7e�E"�.."^'t9�' an. • <br /> r'"'Y,i <br />