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San Joaquin County Environmental Health Department <br /> DATE y3 =1c,1MASTER FILE RECORD INFORMATION "MFR" GREEN FORM <br /> owwert RL1 <br /> CAMPLETEniEFoLLowmGPROPERTYOWNER/NFORAWT/oN., CwcK1pOWNER CvRu)vRrodvtvL nmEHD <br /> tt <br /> PreDarttrvQaatrlttiturE �r� G..swt�r �..'` r rti i✓� i L"f-_ pl� <br /> Lost <br /> e <br /> '^� <br /> Fust Lost <br /> Att <br /> Bttwt+ssNAW 9oaSIM 1TAX tD0 <br /> Owner Honor Address DtavErr'sLice weO <br /> City 8TATE Z1P <br /> Me"*Addrse`c1b, l C`K ��-A tti Sb to <br /> CotrnotuTto"o bam uALD PAtrrwetts*a►❑ FEDAGDOCY❑ 0"1"C) <br /> 01 <br /> FAcarrir igLE �'(f <br /> PACKM100 �/D CAD"REPID# Aco011xrla0 IWO <br /> COMOLETE TWFML OWYNG BUSINESS I FACILITY I SITE UIFoRmd vo V: <br /> Is this a NEw Buskleas LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPT.? YES [] NO.Q <br /> Is this an Exlmo BusMtase LOCATION but a Nrw TYPE of regulated Business? Yes 0 No 11- <br /> BUNMOMFACtirrMSrrEMa /+ 1 (t <br /> S"Aeoteass Sura* BumlessFHONr< <br /> Vvy 3TATff,"f y`t U <br /> ort <br /> eOaMtsp>st/�M/IrOrIfllsMtCt La"To"0000 KKaT2 <br /> Maidng;AddnwsArON'FVMVT*vmFaicAWAoW*w Albrtilort or Com Oftopo;cv J <br /> 11 N -Aefdr*"City STATE Z1► <br /> iKlOCos AM# 00"MBrr. <br /> TNnw PArm 8mAj do bi*o! Complete ifHilling Party is drKerant from Property Owner orFacfltty Operator idenfifted abovo. <br /> Susrrmkaime �M. Attentlon:crCweOf(opflormg <br /> C bLe.�f i�a� � <br /> ltr.rhrpAttdr..a 71 Z.' -�. �_ Pt,otrE � S 3 ` �.� <br /> cffv <br /> STAT!CA <br /> .�aootatTJ�aforia.ssneichmr9se OwNeR FAca-rrvfBuswEss TmwPAtrrvB&Lwo <br /> BILLMG AND ComfLIANQ ACTQWN'L1rDGMENT: t,the nedenitped Applicant,mdly that I am the Ownw.Operator,or Am1%w4rdAjvW of this Basins,and I admowledge that ad PLwTfkFs, <br /> pEvttAPS.FNPVfiC-AaWr CHARGES aodlor H0URL r Cif ftVM associated with this operation will be bitted ro ace at the add rens Identified above as the Ac. .+T.lnrarrPsr for Mss site. I abo notify tbar <br /> all informadw provided on this applicati4m is war and wr ti and that ad regulated activitics will be performni is accordance with sit appicabie SAN JoAtgm CUL:N tr t?rdloaace Codes aadfar <br /> Standards astd S'rATL an&w FieDLRAL Laws sad Rtp)adota,As the undersiped owner,operator,or went of the property located at the above fatuity/site address,I hereby aathoriee the release of <br /> say sad all rewits sad eaviroaaaental assesanbmt inforwAtioa to SAN JOAQUIN MUM"ENVIRONMENTAI.HEALTH DEPARTMENT as to"as it is avw1able and at the same time it is <br /> provided to me or my rtprersttsthe. ' <br /> APPLICAW NAME CrSIGNATURE <br /> 7n1E C- � J:.n 1 _.MVIMSUCENSif <br /> 1N�yroco►r 11LOtNRm1 _ '~ '�y7 � 47 (t <br /> Appravad b Ossa OMw pato <br /> 29-02 10!1210' MASTER FILE RECORD-GREEN <br />