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10117/2002 08:37 2094683433 FIFTH FLOOR rm'= .1 <br /> ON <br /> igp%;n­'N.41 <br /> n <br /> wk <br /> MASTER FILE RECORD INFORMATION <br /> DATE *10101*'Mm�lUNIT IV <br /> OWNER FILE cWcK IF OWNER curREwLroNA&#wrNEHO ❑ <br /> -T <br /> COAjpLETjr <br /> .7WEFOLLoWING BUSINESS OWNER INFORMATION ............... ............ <br /> T-------­-­--------.............. <br /> ..«.._._............_._.._............ ........... .................. Flow <br /> -------------- qj _-)Ltrsci <br /> 0110"IER NAME ------ .. ............ <br /> 11-11................. .......................... SOCSIECITAXICIN <br /> BuarwrsaS N^W(If dArqrV"tTTmITt OAner NmTm,) <br /> Ucatin 9 <br /> OvMRHOMEAODRE53 <br /> STATE <br /> LP <br /> Oft CAg_,,1,Ne.L <br /> I-arcane of (OP60,09 <br /> OmNERMA4144ACO11153 yyOjFFER9NTh"mOwWAddrcs;aJI Aqenlmw- L, <br /> St'le 710 <br /> Moiling AddroWl City <br /> CORPORAnON INDIVIOUALO PA Wpesrtlp 0 LOCALAGEMCTO CoueITTACTgAICIfEl SjAjTEAdEJeItYQ I'm AIIENZY 0 OrTeEg Q <br /> FACILITY FILE <br /> COMPLETE THE FOLLOWING BUSINESS I FACILITY i SITE INFORAIArION <br /> la this a NEM,Stine;LOCATI(IN not pieioumly regulated by the ENVIRONMENTAL HEALTH7 yEa E3 NO <br /> 1*This a.EXIST11113 8,sSin"It LOCAnoMbola NgWTIpgofregWatedSW;nC3S7 Yr 0 No 54 <br /> NAME/ 77 <br /> 1 surre a BUSIMOS PHOW I <br /> SITE APORCIIII <br /> Ae­,I`--QJ­ �&'Je <br /> ST <br /> CITY <br /> TM KIM Y. <br /> Me <br /> Ri I�IPR 111 <br /> Altenti0r: Care Of(Opt--V <br /> Mailing i,g Add,"a If DIFFEREN]"Trom Facility Add� <br /> STATE ?Jp <br /> Mailing Add-7,sritli <br /> is <br /> THJKA P^Kff BILLING INFOWAATION* Comp/ereif Billing Partydifferentfrom Business i-I......................Owner Idendfied above,......... ......--------------- <br /> ............m......................._._........................................................... .................................. <br /> stmmsss NAME I AtOMtUM de'CAIll OF&PIlksela? <br /> PHONE2.1- <br /> Illoill"Q Additions <br /> LIA 7 <br /> 7JO *1 jr <br /> 67AT4 <br /> CITY CA <br /> dgcWAL_a�o_-- for fees and charges OWN" FAGLJTYIBUSINESS THIRD PARTY BiujNG ---- <br /> 91, Mr., Ac 1, he tm4. Igmd Appliettits,cAnify thus I aTss the 0—,.ope,,wot,.o,Awkwiud Ayum*(This B-11TP916 mad I ubm-ICTI-11 111211 211 <br /> =110ar�Acxm-T <br /> pejtwr Fru.PENALTIES, ENr0RczizNT,(XTizcE5=d/41 ffttlftf CHMM+ *Olttd mth this opentwo will be billid to me 2t the Address,identified 3bAye U the 4 &1 <br /> "DRESS(0,this site. I also that A i.tommi..pr.�idd.,,hi, tree sed c�; d that All regulsled utwitim will T- to 2mordsoce M"' 1 <br /> or.geotalheprperty <br /> applicable SAN JOAqUDCC",WOrd;Ae*Codft &D,SjsodArdl and STATE TAdl"FEIEL�IdRg-1.6on,- TDAWN <br /> COUNTY <br /> 1.eWw At the 16..* ralityl3its edtl rtw. I hereby amhorire 'llm M.— of ...� and all -It' -no <br /> ENVIIIIONMESTAL HEALTH DIVISION As,won wit 6 2"Jimbic and At the Two,time 44 pr.Aded to we or y,eprn,+_ <br /> PLEASE PRINT <br /> APPLICANT NAMEsill <br /> GNATURE LL <br /> OR <br /> TITLE 5 T­ <br /> .".,.kv <br /> p ppp <br />