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04/24/2003 10:37 2094683433 FIFTH FLOOR PAGE 03 v >, r•yr 2 x s .X':,y I"` •,..'� S Q »+v�"ii'G:•;£•4�W,r� y...,l1. ✓i �3:Y'^�fi�s'' ��`t3.5°4 nit' {;R 'i4 t •� � �i `g^ � W 3t"'"'• � #; FORM (EH OQ 15IREvtSEQ t16111NT1 BATE MASTER FILE RECORD INFORMATION 511-0is?i "' r kS : k'.1' si`ix:''n"'•v<.;x, ;�r.,r •y. r>�'R..r>;.rr,rMcr.'?�' !�p Si:y'f:' :r' A 7T IV < POPP Ne 4- FILQ CouncrETHEFouowmaBUSINESS OWNER &FQR/NATfoN: CRfeKir OWNER CURRemrCYom F/LEm7-mEHO �.,..r..ur...............r �� /.,.rrr..rrrr.—�r.r�...... .��.�. .............wr.�.rr....uu..r._...u..r u.......... ......... _...—...n r.r............. Busing$$ i �tC�! rf `i—'/�lQJ�p tt4� PNON1-1 6) 1-2 OWNGR NAME ------------ ---- BIJSIN6ss NAME(If dfferent*mm Owner Name) � /`ro / /� ? soc SEG!TAx t D 9 OWNER NOME ADDRESS 79G Tr/L✓�It � Sk /`` r t t7RtVE37'S LICENSE}'1 GSY c rG�"'t r►,� sTATr.64 IJP 5 OWNERMAIUNGADDREss AtL%-Won:orCareof (optiormQ Mailing AQ4ress City State Zip CORPORATIO INDIVIDUAL❑ PAR'TNERsHip❑ LOCAL AGENCY COUNTY AGENCY 0 STATE AGENCY CI FED AGENCY 10 OTHER❑ y} FACILITY FILE Nix. � 'f: .r>ni'<". .y:, t�ss. .«��,,.�.f �o fix. � N. sr'4 :c's �r:aE a+, ,��tiy 1 g??c E t� s• ii?k`}' :x.£:r"< >{� 1F:. $ .,Il•'• r' .od.: `:> :: X.' r+Y.ASi> Fel1 !+_ �i'.'3^ C000i-ETE7'HEFouowtA(G BUSINESS/ FACILITY 1 SITE 1NFORMvinom IS this a NEW Suslness LOCATION not previously regulated by the ENVIRONMENTAL HEALTH 0IVI519N Z YES ❑ No Q Is thG on EXISTING 6usine*s LgcA'nom but a New TYPE of regulated Business 7 YES Q NO Ci SU31NESSIFACIWTY/SITE NAME \ i SITE ADDRfiss J( SUITE# i BusINEss PI{ONE Gnyr �f / 1/.KJ - 37A7E + ZSP .....� ../. ;. .< .. :•. f K' i6 Y i >`+>4.e.<a.a o /t/(6� vr¢ K: :a>r V%rs.< .x+xxaso»;>F.<' 'h�' Y: ; o g ; . `: '+�.`� 'M-+: s*'I' .:i. �...e: -ra •i.�c;'m�i `ti >< ,}s'c�?'>fic; ;2'�'P' ,la,a7`a'�'o€„"r..:^r,�.'r"'. 'C • P M:St Mailing Addre-7xrYAddirss ttention:or Care Of(opeldis/ i Mailing Address City /� ,h // - STATE ZIP db'1ie .h M'.•�;�R.� u:��'�u< � � .��$� °i��p.8� i,�.ts -��a� •-?.f�s� fr;:9-✓y ,,tom., .�ii63 T:a: . s sum• ,r X::';;s{•,ri..i�. .�. ,.;7'"�i ?;;!•. �. .. ;�. 'j z•>t_ e3:Es>• ffe 'ai• } '1: QjSt3 1L, 1iiio o`�i1.} F.F.iroln. <yCtbNi161 ;'§g�"+ ,A';>° .aa ¢¢ o`x�> RUM .. .r. '.s .t.t.3:'< 1:�? 'w $• ; x THIRD PARTY 13IL_LIN6_1NFORMAT11ON: _C_omp_lete if Billing Party is different frofrl Business Owner Identified above. BUSINESS NAMEn`''n<y/L J.', e t 3sc i' (�� ` Attention:oralrtq Of (oP�4 l c 4 .j/cF/aYcr�t' Mailing Add rass 1 l �� ',c PHONE 2e 4 V ka."✓' v CITY Sf� r�* , sTATEe-tsj Iry `7 f 7- for for fees and charges OWNER FACIIJTY/BUSINESS PARTY BILUNG BILL[NG.win{pNiPI.tuNC%ACiCNOWT.¢DCMVNT: 1,the undcrsigned_applicant,certi(v that I am the Otmer.Operator,or.-Lath of this Busintzs,and I sebiowledge that all PS,WIT FESS,PrNAL77Es.Em'V1t=afPNr CHARGES andlor HOL-m4Y CHAA4;s aatociated with this opmtion +ill be billed to me at the addrzit identified above as the..LC—CQ(^rT annRers flu this altC 1 elan certify tbat 211 information provided on this application is Irmo and correct: and that all regulated activities will be perfottncd in ocwrd-nry ",Ih alI Applicabim&&.N JOAOVE4 COUNTY Ordin2mc Codcs and/or Standards and`.JT 1Tti and/or FPCERAL Laws and Rc,ulations. As the undersigned onncr,o0erafor,nr seen or the Prootrty otitued at the nbeve facility/site address. I hamby authorise the mi— or- onv and all sults and environmental a wwnent information to SANJOAQUIN COUSTX ENVIMO.NMENTAL nA.LTHDMSIOIv as soon as it is av rilable aitd et the same 6—;t is provided to the or my representative. PLEASE PRINT I/ APPLICANT NAME 1304 Sf�girrr[ SIGNATURE ”,/-�j/ ✓�// TITLE DRIVER'S LICENSE a RD � t !j:�..�:•t(^.1<:8 R'.. 1+.. 'a�`�+w> I:s�E�.r�:-� �racvis�gK9 .�!� �. H�.�� ii' °y xc <,.. �T3