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02/17/2006 12 : 04 FAX 7077487717 (707)748-7717 2003/003 <br /> San Joaquin County Environmental Health Department GREEN FORM <br /> DATE J �� MASTER FILE RECORD XNFORMAnON "MFR" <br /> UNIT IV <br /> OWNER FILL CHFCxrF OWNER CuRRZAMYONrne wrrx EHD <br /> R Nr pRMATION' <br /> pl�E 7H�AOL[OWING d PttoNE :3" <br /> praoplRTtt OWNER NA— - <br /> M1 Last <br /> First <br /> gqc$[c/TAX ID� <br /> B SNAM w ( S l 00 <br /> r DOUVEI LICE# <br /> ►� r C l <br /> STATE <br /> city 4h t�v <br /> Owner mailing Addr&S& <br /> V state 23P <br /> Maging Address CRy !� <br /> f tin AI DTrtEn❑ <br /> IWIVMUAL Q PAat M9"(W <br /> FAGILITYcPlurrr Ya# ! <br /> Cj clsitla + to t{� <br /> Is this a NEw Business LOCATION not previously regulated by the EtMrtoNMFNTAL HEALTH DEPARTMENT? Yrs � No ❑ <br /> Y[S ❑ No 1� <br /> is this an EXISTING Buslnss eLOCATION but a NEW TYK of re9uld»Qd Buaineaa? <br /> 51,1511,1111551 FAH3ttrvlS 11 NAME 1 o r i j'}�? "?'Y)�S , <br /> � , , //l' •� StmldF B1MNMP1/0N[ � <br /> SM AoDRE¢ ( ,{ ,/y f��r Q lam} } <br /> �} / (�} STATE � <br /> CITY /y/��y�//_-./ • V n I ' 1 M I nOu 1 ! I i .. <br /> '11R�n,�w'DY`rN•rw•/r , 1 , � d I I { ' IW � cN II Ir •I, <br /> ow�nl�ttF�tt � I Inl <br /> ll�nVV��`•^^''�� _ .I_`I.'j AtileedlaM or Care Of fo ona/1 <br /> llailittpAddtewffDXFffREWrfroif r.-&BY <br /> STATE Zm <br /> Mailing Address CRY <br /> I o ; <br /> from Property <br /> CH7ttfleM? <br /> sic Cede APN <br /> is dilerontOwner orFaclllty operator identi�Ted above. <br /> THIRD PARTY BILLING INro: ComPletp Billing PartyAtterltlOtt:Of Cam Of ( ) <br /> BUSINESS NAME <br /> Malling Aridness g 1 1 <br /> STATE �* J <br /> n <br /> FAclurvlBuslNEss THIRD PARTY BILLING <br /> for gees and charges OWNER <br /> dcortt,e{r1i�'that I am the t7+ww,pp"tor,or Authorlscd Agertr of this BusirI and 1 acknowledSc that all PERMIT FEFS, <br /> n r�. �v A( tinwl vnrm✓.ti r; t•the undcrxiQned APP for this site. I alio cerHih thss. <br /> N COUNTY <br /> RrI <br /> latcd Aedvities 9011 be Performed 1n■�cortt et the above Cecil tY sitc a dL{i cap.I he DOau bori=c the rreleme of <br /> pevtt7tas,E,vrux[E,ttFN7 C7+u Gf-c and/or(IOt/RLYCHAkcF-%associated with dds operanoa will be billed to roe at the address ce With all above li be <br /> watcd <br /> dl infureistion pm ldcd on th6 application Is true and correct,ana that All t <br /> Ls <br /> SeAddarda and STATE And/or FT.nEHAI,lawn and Reggulutioom- As the undernigncd Owner-operator,or event o[the ProPK�' ` <br /> auy rnd all rreulba and envlronntenptl assa+{mcot informnGon SAS JOAQLTLN COGr"IN Em, RONNIF.v1'Al.H£..ALTH nEPARTh1ENl-r As soou as�t�,aw�lable and At the flame dtne it <br /> pruvlded to me or aw rrpresemt e- PSE ME MINT SjGNATLIRE <br /> APPLICANT NAME C <br /> DRIVER'S LICENSE# <br /> TTI1E c ' �17 Ui r7�n'� <br /> 11 <br /> Cmok <br /> App—red aY ��L Date p oboe ofllea ptvice�eln9 ttrd <br /> BY <br /> 29-02.002 April 25.2003 <br />