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01/12/2004 14: 43 20�468343e FIFTH =LOOP. FAG= 02 <br /> San Jr- ^uin-County Environmental Health D, -tment <br /> DArE GREEN C=ORM y y MASTER FILE RECORD INFORMATION "'MFR" <br /> S., n a. ,.4iyp e��...n .v (1011ER ID� CASE 9 UNIT .IV <br /> un <br /> i <br /> OWNER FU.E <br /> IQ==771E LOWING aW R SNFORMA77ON; c:yicx,r OWNER eVA4eNtxvoNFmrwmf EHD <br /> PROPERTY OWNER NAME <br /> vl i <br /> First M; Last <br /> 6USt"E0 NAVA 50t SK/TAS(ID# <br /> r[S r/ 4 <br /> Owner Harne Addrew D® UGvI DIUVEk'SLVENSE# <br /> city ST G i / STATE ':IP <br /> S2Qy <br /> Owner(Mailing Address <br /> trailing Aedress City Stabo zip <br /> uwosunm PAA7uEPs4rP❑ FMAWNCY❑ QTMER 11 <br /> M <br /> FAC ITY FILE <br /> FACLU7Y ID# Caoss FuF ID# ActbuW ID# D (y j O Iwo <br /> o <br /> oxPCE7FTH1r-QL4Q RUSMESS I FAC'_( 92"A 770N.' <br /> 15 thtS 9 New Business LocATION not previously rogulated try*J`]e CNI/IROMMENTAL HuLTM DEPARTMENT Y;s ❑ W <br /> Is this ari EXISTING Business LOCATION but a HEwTYPE of regulated Rusiness? via d No <br /> aJet WjFAtarrY/SENAMi <br /> ,t Aaaws S., T r'' Suo«s RUMN110 Pstoese <br /> 5"F4_ <br /> STATE zip <br /> 30ARD Of SifrdlYi90R DrstxLtr I LOCAriav C01M /:/ I KEY1 I 11 Ke'!z <br /> C/I <br /> nailing Addrew iIO1FFERFNTF.»rnFacilriyAddrsx Attention:or Cere of(opobnaq <br /> Railing Address City STATE ZIP <br /> iIG CPDE APH is commurr: <br /> 4IRD PARTY BILLING INFO; Coma'ets if Billing Party is or>a'erent 19Vfr.Property Owner ceFacility Operator identified a-hove. <br /> SUSINLs NAM Adantion:arCan Of(optional) <br /> hiring Addrm O 4 a (7&p-o, 1173 / )' Y/ j <br /> STA.T, 1,14 21P y,2o y <br /> AY"aAxAoaPjw forfees and charges OWNER FACILITY/BUSINESS THIRD PARTY BILLINO <br /> eetletaa <br /> .vr,_ront•�«vrr A,,rnanwr rnrarnT: I,the andersipmh'th <br /> d Applimt,urttat I am the Owner,Operator,.or Aa6Mrri Agent if th:s 6usirtess,aad I aclmowkd;e that 0..P£.4.MTrFEES, <br /> VALT/6S,FWWCKM£ATChWPGES and/onr 110UNLYCNAROES nswiakod with dila operadon wM be billed tome at:hc address idenW*d INhe as the AccaMTADDactc for this site. I alsc certify that a:l <br /> umadon proyidtd Da this applieadoo is tree aml oarrcet;a,d that all mcgulated activities will be perfumed In accordance with a0 applicable SAA JOAQC1N CDUNIY Ordinance Codes.od'or <br /> ndards and STATS amilar FEDERAL Laws and Regtdadoas. As the undery;-gntd owrcr,operator,or agent or the property ixa2d a the abovt hciii y,Yite address.I hereby atrthcr=the micast Df <br /> and an re+uib and cariroamentol assusrnent fiecrmaUon to$AN JOAQUIN COLNTY ENVJR0NMZN7AL HEALTH DEPARTMENY u won as it n available and at the same dmc It is <br /> ,,'d ed tom or myreprpetltadvt. <br /> PPLICANTNAME ') T� SIGNATURE <br /> T LE DiLiVER'S LICENSE# <br /> h MOTOaD►Y ieeoutam) <br /> pproreII By L_- W16 Z3 � At=Srlang Oflroa PrcastaM CoR.Pistad by Dace <br /> 32-002 April 25,2D03 <br /> // V/3 <br />