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12/19/2003 16:50 FAX 4002/003 <br /> 1.2/19/2003 - 14: 41 209468": FIFTH FLOOR PAGE 02 <br /> WWI <br /> V!41M <br /> yy <br /> . ......... <br /> rff- MO.! <br /> ....... ..... <br /> FORM (I;H00'!(AI1,-110e0 gill its?) <br /> DATE jj�ece,. MASTER FILE RECORD INFORMATION <br /> N <br /> Al 0 <br /> UNIT IV <br /> ;IR .......... <br /> OWMER FILE <br /> 0jWF1L <br /> CoAfp,LErE-rNEF jrOLLOWIMG BUSINESS OWNER INFORAaj4ECv�g 40WNr!!A Cu9,TAFNrLV.... SWfrNf=H0 <br /> IATION: ...................— <br /> .......... .......... <br /> • ................ ........... <br /> BUSINESS <br /> OWNER NAME ————————————————— <br /> 11. ,............. AW................ <br /> S—'_._...-_..........._ <br /> 17Mee)NAE(11 aitr <br /> 9C 4Namj- L C 46 50Q$EcJ TAx ID ML <br /> OwDRIVEA'S UCENSE# <br /> NrIR rz HOME ADDRESS <br /> $TATr. L/,q zip <br /> Ory <br /> z <br /> OWNER MAILING A0017rSS (ifofFFEREN T from ownerAddress) i Atbuntion:or Car-7 of (upffonaf) <br /> i Mailing Address City i State Zip <br /> T <br /> ,ypr np()MFR1W,-5, r,':Ncy STATeAmNarlEl FED AGENCY 13 OTHIRR C <br /> CoApoRATION CZ INDIVIDUAL PARTNERSHIP❑ LoCALAGSNCY C COUNTY A <br /> V r) 1/ (2 FACILITY ME T? n l Y t1 It Lf TLD- 71 <br /> MN <br /> C0A4PLATETHCF0LL0W10VG BUSINESS I FACILITY/ SITE 1AfF0J?AfA77401V-- <br /> Is this a NEWelLainess LOCATION net previously reQulsbed by the F-WROMM9AITALHEALTH OtVi840"7 YS NO 0 <br /> Isithis an EXI&nNG Business LocAiiaN but mEwTymQfregulated ousinetan? YE5 ❑ No C' <br /> SuSjNESS/F:AcIuTyfSjTr NAME <br /> SrM AMORESS SUITE I$ BUSINESS PHONE <br /> $*T5,1 zip <br /> crry <br /> �,,�Mawm miR, <br /> —� z <br /> 4 W <br /> Attantion:or Care Of(ap6onfil) <br /> Mailing Address jFL`1jFFEo7jCNT from IvaclMy Ae&frags <br /> STATE = Zip <br /> Mailing Address City <br /> A c. . '' Z, <br /> 3,41 • 11 <br /> THIRD PARTY HILLIHG IxFoRmATioN- Complete if Billing Party Is different from Business Owner Identified above. <br /> ........-........... ... ......................................... ................................. <br /> ...13USINaSS NAME <br /> AtIontipri;(N-Care Of (qP6grj;R1j <br /> tj 0�r <br /> Mailing Address O-Cro r a C- PHON ZIP-2-6-2 L& <br /> CITY 0 7 SYATE <br /> U!aD—B"s for fees and charges OWNER FACIUTY13LISINUS THIRD PARTY E31LLIN <br /> 171MLLNO kMuCW,90g=, : 1,the undersigned-Applir—L certify that Iun the O"cr,Opzr=or,orAuMorizedAg�101`11%1-s BusincsL—d I ackno�ledggc that-11 <br /> IMP` IT EmFoRcnirEjYT CRA-RCES and/or HOURLY CgARGEs ;L"ociaied with this o0cralpon will b,; billed to -e at the :tdd-1 ideatificd -b-v- As the.-4CCOL <br /> PEPtar FEW, - <br /> i4z>D for this site. I 'Also cardrY lh2t All information providcd on thi, appijeatioR i�true and eorr;ct.and that all replaced zq;jjvitjes will be performed in accordance With allg <br /> applicable S.4a joAquLi CoLrNTY Ordinance Code-i andlor Standards and STATE 2DJIQC FED&mc.Laws=d Regulations. as the undersigned uvraer.operator,or agent <br /> located at the above facility/site ad-irwd, I hcmby "rhorizi; the mica_ of any and alS rQults and an%iranmvnr:J assetLgment information to SAN JOAQLIN COUNTY <br /> EyvMONMiENTAL HEALTH DIVISION as aeon it is available and at the same tune it is provided to meormyrcprc5cntacivm <br /> Pt-EASE PRINT <br /> APPLICANT NAME SST OfSpSIGNATURE <br /> DRIVER'S, LICENSE <br /> TITLE ocnillmonj <br /> 777 N <br />