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12/19/2003 16:50 FAX U002/003
<br /> 12/19/2003 14:41 2.219468" 1 FIFTH FLOOR PAGE 02
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<br /> r`YI �� 2003 MASTER FILL= RECORD INFORMATION Foau {t0100'S�AtihrEo 08t11ro7
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<br /> OWNER FILE
<br /> COhfPLE7F
<br /> BUSINESS OWNER IMFORMATIOIV cr+ECKia owNER CtrRRsNrcYONFicswrrNEHU a
<br /> ............................................... ----..._.......... _....-_ - - - -_....•--_......_.-...-----..................._`__,..•l ----....,._.. .....................................
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<br /> BUSINESS i i PHO++E
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<br /> OWNER NAME ^-----"--------------------�—--------.,'wl
<br /> ............._--- _ ._......._ ,.................................... t......., ................ .
<br /> Bal$ SS NAME(11 dilfBr'errtli-o rt Q—er Name) SOC SECT TAX 10 tF
<br /> rysSr'G4.dS C S/< Lr4 Ih �tJ�u�7 LLL G(�b �'�'ZJ CGy1c
<br /> OWNER HOME ADDRESS 601
<br /> Ft li Gro ti Sf� .J u e cif SD ORIvQi'S LICENSEiF
<br /> STATE �/� ZJP j� a tr I
<br /> OWNER MAIUNGAODRrSS (ifO1FFERENTfmmOwnsrAddrtx) Atbcntion:orcareof (optional)
<br /> Mailing Addeo-,a City ' SL�ta ` 2i p
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<br /> COOAPORATIONINDIVIDUAL Q PARTNERSHIP❑ LncaLAGENCY❑ COUNTY ACENcY Q STATE AGENCY❑ Fm AGENCY❑ OTHER❑
<br /> ~ Ap A DD n FACILITY FILE j
<br /> 1'.yi7''�`♦S� � � I �,'t S,'��''S - ;:y.. :!,*. �� �pp�r.,�y}`�AFP %I '1�} � {.s. � �PY� Kl�r ��� ,rt+w��,�.��![,,�
<br /> .�i�r'.� $i��a11.Ti ,t+9,Wgt•:e:fi i '�ta �> t�: :r?itN't:i� ', .Kt f.M'S'l.•lM�..r.e"b�l
<br /> COMPLETETHEFOLLOW/NG BUSINESS / FACILITY I SITE INFORhonom
<br /> Is this a NEw Sunine'Ss LOCATION not praviOUSty rcgulatad by the F_NV1Ra Nrt£NTAL HEALTH ONISION 7 YS I NO
<br /> is this an Lxt3T1NG Suziness LoCAnON but a NEW T FIE of regulated Qusinesa 7 r YES ❑
<br /> BUsItJESSI 5AClL1TYISlTE NAM -
<br /> 11
<br /> SITE ADORES3 SUITE If: BU91NE33 PHONE
<br /> $TA Z1r
<br /> QTY o
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<br /> ?5 1y I: 31 t.�w •, 'ffi � 1 efA�F
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<br /> Mailing Address if DIFFERENT from F'aciNyAdWrsss Attention:oe Care Of(opt}onaQ
<br /> Mailing Address City STATE i Z:P
<br /> ro:•R ♦ a S h6tw yt° lt,iy�.k Wei; y' �. .� 4b Barg-i.- a
<br /> £ rl1t°5Y t,.�. xy t 44',' '4iwr• ''
<br /> ."'�?�•Yf<`a"3'F4w.kf.,a�
<br /> THIRD PARTY BILLING IMFOFtmAnom Complete if Billing Party Is different from Business Owner Identified above.
<br /> ----------......................-r------..............,.-._ ......._............r•--._.................•..............
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<br /> BUSINESS NAME! ptn' rile (qPff hl
<br /> AL
<br /> �v ✓'U C.l GS t �ti C
<br /> Mallhig Address l U tfU r o c ae w a y f s, �iC9 U i PHONt� O 1 -1 _ ill
<br /> STATE LP f e6 o
<br /> oQg ,qg for fees and charges OWNER FAc1LPiYlSU51Nus THIRD PART'BILLING
<br /> RILLm,AN--n("'pMPtAANCs 4etrtavn.eDCNfE,Nst 1,the undersigned Applic—L certify that I sat the 0"47,Op&RzWr,or.{urhorizadAgetre or thls DuMacss wad I acknowledge that all
<br /> PSR+f/7 FEES, PrPILt1PS CR.tRGEs and/or iYoURLY CW RGES zssoeiated with Ibis Dperation),Pill be biUcd to me at the addr ideetificd above u the. rr
<br /> -IDDM .RES. for th6 Bite. 1 also certlfY that all information provided on thi, application i%true and eotr;ct.znd that all t-plated uaivitia will be Performed in accord="with all
<br /> applicablc SAS JOAQULV COLNTY Ordinan"Codes and/or Stwid2rc!5 and STATE andlce FEDI%I L Laws and Regulatiar. N the undersigned owzwe.operator,or cogent of the properry
<br /> located at the abate racilitytsite addrma, I hcmby authohzc the —I.— of any and alt —ults and cnrita :.aseYxmont information to SA1N dOAQL7N COUNTY
<br /> E:YvMO`',AZ,`lTAL HEALTH DIVISION'm soon as it is a+milable and at the same time it is provided to me or Dty rcprescatAtive,
<br /> PRASE PRINT /II
<br /> APPLICANT NAME S� (�,tt� ,r OfSp�k� SIGNATURE U
<br /> TITLE_
<br /> y r.c c t DRIVER'S LICEN:5 0 r7 2 -7 cl
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<br /> A: a se aO�itl ` t d 4rit7',t3 ' �V5
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