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)U,Al I 1 F-:UII <br /> P. S <br /> DATE f�I IIf 9� <br /> MASTER FILE RECORD INFORMATION "MFR" <br /> Sn�_o�rye EoltkY�p_Ile.�4'+�+: <br /> �J� /�DGG36 OWNER FIL UNIT IV <br /> CIPATLETF. TNEFOLL0WINGPROPERTY OWNER INFdRMA770N: Cw�KTv OWNER G'V0?RENTLY0r1A&FWjTNEH0 <br /> PROPERTY <br /> PHONE <br /> OWNER NAYS <br /> w war <br /> BUSINESS NAME 1 1 �1 <br /> 'a� Cf1Y/-fnUf11 Cpl )Gn jT� n(M SxSEC/TAxIDr <br /> Owner Home Address <br /> DAWCA'S L,cEeesE tt <br /> City <br /> y� // STATE zip <br /> y ew <br /> Ownar Yalllr,9 AdOnaq 3c J -TF-Cc e vW IaC 7- 3Roy 1, a.v' mad zs�t� <br /> Mailing Address City j <br /> O Ch Im Zip 9So7b <br /> ORPORATION❑ INDIVIDUAL❑ PARTNERSHIP❑ <br /> f� FED AGE1rCY prtiER O <br /> l/ '. <br /> FACILITY FILE <br /> :3�' <br /> COMPLETE 7'HEF0LL0W7NG BUSINESS!FACILITY I SITE & ORMAr70N: <br /> le this a NEW Business LOCATION not previously regulaMd by the ENVIRONMENTAL HEATH DrMloH? <br /> YES p Mo r�( <br /> is this an EXISTING Business LocATtoN but a Nov TYPE of regulated Business 7 "� <br /> YES NO <br /> BUS INESSIFACILITV/SITE NAME <br /> Ao gti and /pct Ts Ja�c>/ <br /> S+re Al>vRess <br /> --_��t���P_Vj5 ✓^'1✓� i '�l/i InG S �bCJy $ /OD..S 3uITEX BuslNEss PHONE <br /> CITY 5�v/,A-V4 ST/A�TE zip -1203 <br /> 91, <br /> ! <br /> ,/� I l <br /> �,•4Ts! V,}�:Fjll!ffiL�ii _f.,:,. T_1t___r) .,F .r .. ..,;�'Ir.Kcnl" —.4K}.'Y.'..: 1 _.. '..11 <br /> Mailing Address XDIFFERENT <br /> from FecrtityAddrt9sa Attention:or Care Of(optjonatf <br /> Mailing Address City STATE ZIP <br /> i. t C.o�1►�fplri;u. 64147`r rrrq,, I r« <br /> THIRD PARTY BILLING INFO: Complete if Billing Party is <br /> BUSINESS NAME ddferenl from Property YOwn r orFacllity Operator Identiied above. <br /> Attention:orCara of (optAana# <br /> Mairmg Address r <br /> tD L Roseftijod Blvd. PHONE 626 35/—SWIX <br /> CITY q <br /> 1G.SQCIPnC� sTATEC�I ZIP -7- <br /> dC990A ADPTC$s for fees and charges OWNFR FACILITY/BLISINESS THIRD PARTY BILLING <br /> BILLING AND COMPLIANCE ACKNOWLPIWAIVrrl; 1.the oadersipntA.alp "ot certify that I aIn the OwReT.Operator,orAuMorfc.d Apert of this i3usincss and I Aeknpwl <br /> t'(X+fIT IrE�Y PEYALn6f,ENfr)RCZS►(�17 t7/AXrES and/or HtX'FI.Y CiIARf ES aaeociafcd with th{t nperatfnn will be billed tome at the address ideut;&d aMwt—the �U-UI�ADUke%.% <br /> for this site- I alto n►rYify that all information provided on this application 4 true awd torrcct:wed that all rerulau,d activities wilt be performcd io accordance with all.gpPI;CNI*S10 <br /> Jo.vQUIN COUNTY Ordinance Cnd"sad/or Standards aad ST,%TE and/or FtDrn,AL l„►a end Peru:rtiom, Aa the andervifned nwner,of xtur.or ascrtt of 01f pt open•:V c.t.d nt the <br /> al,pve facilityhitc addrma, 1 bercby anthorim the release nf R.,y and all resvha and ev%lronrser,l:tt r^e..•tmeat information to SAN JnAQ . <br /> HEALTH DR'IMON as SOOn ar s it a•ailable and at the uveae dere it is debrided bo Tse or sty rcercrFrttr+,_. IJIN (;tJl_NTY' f;1Ty7Z0.'V11E,Y1'.sl <br /> PLEASE PRINT <br /> APPLICANT NAME I e0"Ny Y B k;p I,� SIGUATURE / <br /> TITLE r • DRIVER'S LICENSE M G"1 <br /> .Q (PHOTnMpy EEO,pinni <br /> ,r yy - <br /> tF, <br /> �W✓1..W.1��ny -ValB ,A�II r <br /> _ A <br />