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o rr hL <br /> 2ES4EE� FIrr F' USF <br /> �1�j tiflc Usah£Se?{Ces^1 rTtSJiiD, <br /> Sco . iileflt2 �,1T : 3tTrt `, F <br /> .�. BFl ill3£CSt1U#) ann 1. .f ` t <br /> _..,....__..-, FORM (EH DD t51PEv1sse Osn lrJT <br /> DATE MASTER FILE RECORD INFORMATION w1 `' <br /> X17,/ Vvi 3a 1,i 'r ,3"ea:it i'"`Nn i�ti',, UIV�T 'ol V <br /> to!vr `i #'�.R�rs+,ft0lx'4`.': <br /> AUG 9 2001 OWNER FILE CHECXIF OWNER CURREMTLrONFILEK7THEHC <br /> -.. r , BUSINESS OWNER INFORMATION_' --- ........_...---.._......_..._.. <br /> .. .r-- --^-..__..:............_...I, ... <br /> COMPLETE THE FOLLOWING r PHONE <br /> r-- <br /> -_-_ ---�------ ------------- <br /> OWNERNAME <br /> ........................_....................�............ <br /> ..C.fAI.... ._.�. _N1..._....... .. <br /> --•• 1 _ _ sac Sac]TAX 10 <br /> BUSINESS NAME(If diftrsnt from Owner Name) 7,4�` S A C <br /> . t\ DRIVER'S LICENSEE +� <br /> OWNER HOME AOORESS <br /> STATE — I LP <br /> ,.. CKY . <br /> Attention:or Care of (OpGOnm11 <br /> OWNER MAIUNC ADORE99 (IfOIFFERENThnm OwnerAddreapl <br /> i <br /> 1 + C(.ey-'�- ! �A- i zi -14 Cell <br /> State <br /> Mailing Address <br /> Cl �'� J- WoAhJ <br /> CORPORATION INOIVIOUALm PARTNERSHIP❑ LOCAL AGENCT0 COUNry AGENCY 11 STATE AaENcv❑ FED ACENCr❑ OTHERO <br /> 411 ���� 3 `5 FACILITY FILEIr <br /> E FL§ri€ilM+ ¢ xc Ire I �.sv fiy ev 3 s;kt£# Tc'tt'c4tc.» .• � clt�iaizk'"'"'. t ' '� ,' N el' <br /> arae P �'�,'�si�«°1Iii14(y��ht 1�R�€�*�ti�itp �•alr��,�a <br /> COMPLETE THE FOLLOWING BUSINESS I FACILITY I SITE E /NFONMAr10 PC _ YES O <br /> Is This a NEW Buairoa3 LOCATION not previously reegdated by the EWRONMENTA HEALTH DIV1510N'1 YES R NO 0 <br /> Is this an E xI9TING Busineas LOCATIONNbuts NTilu,"'Od <br /> ('�..BuineaS 7 <br /> LBUST ESSJF muTYISITE NAME Jh eLL _--- - <br /> p"— <br /> i SUITE i BUSINESSPMNE <br /> SITEADDRESS <br /> STATE/Ay1 LP <br /> CITT �' C(rI- • <br /> �✓� �, � rt t r� c�4' � i�fir£ ;il �rI"i'`��a.��'����sliyN���� <br /> y t i ry Ii tkd°r 1 r t� 1 Y¢I 'ttlEa4d iS "F£a yA wu <br /> Attention:Or Care Of(OPOanal) <br /> Mailing Address if01FFERENTfrom PSClrty Add/zs <br /> STATE 1 zip <br /> Mailing Addr "Gty .. } <br /> Yee <br /> C r.lYc'jx ^,j'IR'lrwT: «»v«� :IIr#y t Ili yl�yw,x ° e� <br /> b�x�f��'��'I '��'t�if�iSt/ f1EctxRPxC1'z.2�tY+E4��t�bf(IkbL�k�.. .3Y r'Tx i Z'a <br /> ,- <br /> THIpDPART761LL1 INPOfWAT10N- Comp)ete/f•BllltngParty rsdrfferenttromesuslneao .. ner . <br /> AIIontion:or Care IX (opoara0 <br /> PHONE <br /> Mailing Address � O R � !1 /L �//,//f�/�V� /j,''I •� <br /> /O, STATL� .� 1 zip <br /> QTY �lDu 7JL 0. ef. <br /> g�yo INrA ORFs3 for fees and charges OWNER <br /> FACILITYIBUSINESS THIRD PARTY BILLING <br /> SILLINC AND COMPLI.WCE ACT.T'OWI.EOCMEVT: L the undemigned Applicant,certify that I Am the Orrper,OPo�ar,air`1arl arced rigstu of thu$�IaCfS vW I adalorlhe So that all <br /> PERAGr fEE3. PENUDEs. ENrnq hT CRtRGis aodlof)fdURLT CR3R('1'.4 aaocisted with this operation rig be billed to bre At the Address Identified above m the.{drOU.Yr <br /> a, O/IRP_RS far this.ite. 1 also certify[hat all iaformatioo provided on this appliation c me and correct: Aad that all m. lated acuAiles wig be patfanwA in aecardsoce with all <br /> Applicable SAN JO silt, CO a rm OV 11,20 oe Codes and/or Standards And STATY andlor FEDERAL Lars and Regulations As the utldc igntd Ds ,,. <br /> operator,air agent of the property <br /> located At the above facility/site address I hereby aathuriAe the rci•Asa of any a.w All r.edu and tor,".menral seseasmenr ipformatiun W SAN JOAQUIN COO' <br /> I'.i`IVR¢ON)AENTAL HEALTH DMSION As soon As it is o•ailabse a.d M the same time it is provided[a me or my reprasotative, <br /> PLEASE PRINT /_ 1 <br /> .H- SIGNATU <br /> APPLICANT NAME <br /> 1— DRIVER'S LICENSE 01 _. ) <br /> TITLE n'Y)(�I I ZC{� ,( 1Fs ne <br /> Aoaro ed HAii' .Win .,-y a 1c �E ACcwmng 6HIa. feaAeti,Xs a q" <br /> p^y <br /> £ k'P" S 6 J, F•F''"FssT� u 'u'; ".irk <br /> OsnP�`s 7 <br />