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9-10-1998 10:28AM FFtUM r. a <br /> FOGY �310D tg(Rtsrem GB/ttm� <br /> �ATe 9-24- G� MASTERFILE RECORD INFORMATION <br /> .e.oNe ewe..v UNIT IV <br /> OWNER FILE <br /> COMPUMETHEFOLLOWWOBUSINESS OWNER INFORMAT/ON.' Q+EUIF OWNER cuafm mro"mtxw EHD <br /> BUSINESS i PRONE <br /> i <br /> Ow,u&x NAME ------ --- --1-- ..-------------------- <br /> Na Y LLU i <br /> BUSINESS NAME(N dN/Nrsrlt*=VOt Name) TOy Ate/ Sly , 1 SOC SEC/TAX 10 <br /> 'v't l "E L t <br /> OwwEG11 N/�O�tM�E Aootmss zy2o w, KET'TLEMPtmIQ LkNc Dmwra ucFxvss <br /> CRY W L I STATE ZIP : <br /> OW ERMAWNGADD� (NDIFFERENTIiwn O» A4dnaa) AtbmdipL-cr Catad (Gpt/arrt0 <br /> Mailing Address C71ty Stat zip <br /> COPPO WfnON❑ INtTNIDU c PARrmemmPO LOG ACENCY❑ COUNTY AQOICY CI STATE AGENCY❑ FED AGOIt:Y❑ OTHER 11 <br /> FACILITY FILE <br /> 5. <br /> COMPLETETHEFOLLOMMG BUSINESS I FACILITY I SITE INPoRm4nom- <br /> Ie the a NEw BtO:nees t cG no not pRsviotmly rtsgWdmd by the ENNRDNIBlTALNFXTN DIwION T YPs 0 No O - <br /> Is the w E*=Na Boairtess Loc now but a NEwTIrm of rngutdmd Bumi,m7 Yes O No d <br /> BusINSaJFACIIm/STYE NAPE <br /> TO KAP( SHL- <br /> SRM ADDRESS ` S1JffMdf ! BUSINESS PHONE <br /> 4io W. .ANE <br /> CITYl...OD ± $TATE € ZF ' <br /> , <br /> I� <br /> Mailing Address HO/FFFStElvravn,F.raSiy Addlmr f?O. UVX sO�D aturAlow or ere ortopfiaml <br /> ND <br /> Maaing Addrnla CitySfATifA ! aP 9+5' . <br /> TNIRD PARTY BILLING INFORMATION: Complete if Billing Party is different from 8usiness Owner ldendfied above. <br /> BUSINESS NAME <br /> Ma:ting Ar7drerls �.0.13 ''BoRb .. <br /> «T <br /> pg storteesandcharges OWNER FACLnY/BISa$SS " TtffimPARTYSILL G <br /> Bdewr Arve ConIPr.TANrs ACWtl7m'1.¢DGNFNt; ;dte_ .�Appi{ca4 oYtllq the[Im the A..u;OFevmr.trA�r/,{gtm of tbn Basom,asd I,tdow.ldg,�t�tyh�u�z�0 <br /> PIR1t1T F= Prt� ZNVVRCMQW 0rU =medlar Hot=r OUR=225e0Mcd wig slit epImEw III be UAW In me m the address bleatlbW ebote Y the yg�..i.. <br /> ADD for this sit. I ayo ctrIlly&Y ap SSa,vdet pros:d.d m tSS appl-etl is am amd tart ,ed that aD eyslaed S Brice+a be pm r.o ju a®tdartre with all <br /> appliable SAN JOAQtma COVIY[Y Ordlmm Cada sadlar Stavdvdm sed STATE and/or Pim19At,Laws and R.gvtdam. As tbv ntduvgped oNmer,opoater,er agent of tba property <br /> Weed at the above tuZzy/sits addrsay I bmnby mb"im me n4,r— of my ed aD temks sed mrvemwrnc%l eaetamm mformatios It, SAN JOAQUIN COUNTY <br /> ENVDmONMF.nAL SE'ALTH DIVISION m sots as it u 91%aable mmd Y the saax time its pm W d m mo er my reprtemtfi%, - - <br /> t PLEASE PRINTy •� <br /> APPUCANT NAMEK _ OD t ..SIGNATURE %!Ok4A,l\ ..�L- ✓Y4cr?nses, LLC- <br /> -7 l <br /> 1 GG p DRIVER'S LJCENSEf I <br /> TRLE Zi` . `•'}-... .Ct�yv� 'VYI2t, 1.7�VIYDy11�QVC�I.I. �PNDTDrnwRmmttmt ... - . <br />