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3-16-1 999 11 : 1 3AM,'"" � P. 2 <br /> c��V �.-. �3�➢Y-^."i,^: +�vr'. "� "rhrvvo �q2:,x�w: <br /> (} v PORK W40015(ReASE006-11107) <br /> DATE Iv —( a 7 MASTER FILE RECORD INFORMATION <br /> t. » : _ L ; ::�: UNIT IV <br /> OWNER FILE <br /> COMPLETE THEFOLLCWI.VG BUSII NESS_OWNER &FORMAT/OM_ Cs4 cxtr OWNER Cu.QflFN tro f cjLC rHEHO Q <br /> PPOw <br /> OwNEFt NAME ------ L-t l—t b(Kt ci —f 2 6 --------- C�� <br /> SusmEs3 NAME(If d}/Wwaf 6-cm Owner Name) E SOCSGc1 TAx J0 f <br /> OwNERHOMEAOOREY9 - ? 0Rrw10t13UCEWM0 <br /> �Y $TaT E 7111' <br /> OwNERhWUNaAOOAESS (1f01FFERENTfrvmOwwrAddnmsfACmrKon:arcm-0Od (opNarssd <br /> } yf�4, State �'rtlQ; i <br /> Mailing Address City C71 f 1 I1 +U 1 ►Ls f10(J — �� _J�Ox <br /> CORPOttATIONCr INOMDVAL0 - PARTNOZ3HIPC LOCAL AOOICYQ COUNTY AGENCY STATEACEN.,f FtDACt]#6rQ' OTNERO <br /> D0�'C7 FACILITY FILE <br /> COMPLETE THEFOLLOWING- BUSINESS I FACILITY/SITE&FORMA770A <br /> Ia this a NF-W Busrnesa LOCArops not prtn mssly regulated byttte FNMA MN94TALHFxTH Om="Z Yt S Q No. - <br /> is this an easnNc Business LOCATION buts NEW TYPE of regulated euakm=7 Y>:s'Q' No.z <br /> 8usINE4s/FwciLRY/StrE NAmen i L W . , S G Cr k-T Gtv <br /> SITE ADORE3S StarE 3 8USLMESS PHONE <br /> `7 t�� IJUk'–Tit A-D A9 I P-cs ;C2o`;) qct -722 <br /> ciT,. S ZIP" <br /> ;zoo; >5� ��ii �t�v c �rx .{2 i f.• �t�2�"; o '�'� r i St>• �v •,Y�,�•� 'moi. � h .<Q'`.'e ,.i.��:'- :: Y.a,•m.��'\7;��� vF .sem;{`. .':�.� �i:�b^;:i�tr• .� •`d;�f�r :Fa <br /> Mailing Add.»ss.rYD1FFEREN7-fium FaeUUyAd&-*= ? Athm7derr.ser Care Of(optiormmg_ <br /> Mailing Address City STATE hP` <br /> RAW <br /> a,-��o •�`'.� '�i G �Ya '+'Xs..u• t <br /> M <br /> .Z• t: .'...x� > M. :{^;Ln�zc^t� �£ a ama <br /> .:rZ NAM <br /> cu <br /> THIRD PARTY••'BILLING INFORMATION: Complete if Billing Party Isdih`erentfrom Business Owner Idefy fedabove: <br /> BUSLNEss ALferrtiort:arCan Otz(dpt(drmrf c <br /> w <br /> hailing Address PHONIE K i t ,G., s f i <br /> 6 <br /> crrr <br /> STATE <br /> far fees and charges. OWNER FAcairy/BusmiEss DOM PARTY <br /> Bnatrc�rro COMCL Axcr•ApOvow[�pG`rFzrI 'I.the mdmigned AppNcaat�oertlty tLae run the Of.wo,opmom.erAseLw;raditgart elthfe gasinesa asd.Lac3osewtidge ehaeilr <br /> PE&wr Pr1 4L77 ,ENPbRxzm!Nr OrAAGRS and/orHODRbr Ct4nea aeocated'with.this operxdm will be-bM@d:m neer at titr address,khmd icd!above•,as the o1 <br /> DO tT for tbis sits. I also certify that.all.mfortnadca,provided,'ar ibis app3cado.r is trcm and correct sad tha all ntadascd ME-16, So will be petfa 6m !Zw aeoerdaare-ith`all' <br /> appGmble SAN JOAQVW COuM T Ordinance Codes aadforStandards and-STATE and/or FMOL,,L LMs sad R&CA26acs- As the usdnsgmed owner.operator.or agrttt of then Property <br /> located at the above, fadi8cy/site addre%.% L.hembr aatbari=e.the relems of any a" as resnits and eovircamemmi•mos. mfenmacoer q 3A1V-JOAQUIN` COM= <br /> S.YYIRONNI MEITAL EMALTH DLVISIOK as soon a it is available and at the same tima it is provided'to moor my reprt"atati'rc - <br /> "PLFAsePRINT t1!� - , ` ., ry`�•_ <br /> APPLICANT NAME \� �T d SIGNATURE <br /> ? i / RIVtR'SUCENSEs <br /> O <br /> Trrt_E <br />