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,�- <br /> war IEH W,SLilEvra®Ogn,N'n <br /> DA-,E ZG DD MASTER FILE RECORD INFORMAnoN <br /> UNIT' IV <br /> O62D&0„71 OWNER FILE _. <br /> CoNpLETETHEFOLLOW/NG BUSINESS OWNER INFORmAT7ON_ CHEpf OWNER ClRAEMrtrOffALE*"N EHO <br /> sImIHEn c - `.. <br /> PHONE <br /> OWNER NAME ___--__-___— n ` !• <br /> Fra ^ P m <br /> BUSINESS NAMEIrf a7/lbrsntsiasOwsser Name) /^// -,. _ _✓-�' ^ i SOCSBCITAXIDi <br /> OwNET3 HOMEADDRESS <br /> c ty ? STATE zip <br /> owN muuma ADDREss WDIFFERBVT�s(�'an,0�,�M.MerAekr ) (}ry I- € AtmOtiow u^Ct�� of (opbonW7 <br /> MaTing Add> city <br /> 6 0 0 ��' '-�`"`�� laM,y/+^ I E� /�,Qc��j �, T'[ '� <br /> GAum^ SES 3-v7(�; <br /> CORPORAnON INOMOl1AL❑ PARiHERFUP❑ IAaLL AGaaa'❑ COUNTY acENLY❑ STATEAGENf.T❑ Fm ACQIOYQ OT"ma <br /> F714 / FACILITY FILE <br /> -•.-�.m-,_w--x.%a:�x.,o�-Y r,�...�.vs�:,' -:. ..+D?r_..w, y:�°: aa.Ya,"�:`:� �....:m-<cr -':' 2�':P,�zW" x.73 �z. <br /> %�.Acrcxr.Yi[��. .v� •• cis .::� tis .,;�` ', �- �.,��'..,_: <br /> COMPLETETHEFOLLomNG BUSINESS I FACILITY / SITE INFoiumncm - - <br /> Is this a Nt Bt ineas L oC nom notprnvmu*regWated by the ENvmmImiE nALHEMSH Qm m T YES El NO Q <br /> Ls the W EMSTING&Min Lp TION bUta NEW TYPE at regUW[bed BUMTN=1 Yes Q NO Q <br /> BusiNESS/FAau Y/SRE NAPE <br /> SITE - _ n I SUITE# BusDE.,s PHONE <br /> v ( 4 r <br /> GTTr' <br /> Al( <br /> , <br /> '�irsA Cimrnwansr,_.�, irte-sasnwCoriK,..• .- -,-- -R�:: : :..:_: -yc <br /> Maung Addrese i/DIFFERENTII a n FadlyAddress Aftnnbl or Care Of(cpbormll - <br /> Mailing Addresv City - i STATE [ ZIP :`�:�-•.i <br /> �;Si�F.O}]6"'�;_ r�e3 .y nz.� �;.au''�� ,, s., :-. .7•£' IS�`�.^��.,s�•..•..x <br /> _ a <br /> THIRD PARTY BILLING INFORMATION: Complete if Billing Party is ditferentfrom Business Owner Ide»tWedabove_ - <br /> ElumNESS NAPE"'.-. < / .-. - Attxrtiorc arCar'e Of (apOorml/ x <br /> >I//j-/ <br /> Mailing Addreae ..- PHONE - - <br /> 4. <br /> CITY -: -V l�a : STATE <br /> Aa=VAMADORF_SS forfe and ctmrg� :OWNER FAcLn dBusmEss THRO PARTY Btt.�- - <br /> Ttn rme AHD COMPLGNCE AQC40rYLLnG4prtT L the mde gmd AppL _. cvah tb;w I m the ONwc Opovroe,or A••dm i-•aAg of mu 8.z. a d rack w-wW go that all <br /> - ,c7 F=s. PLfbtLM=. El fj=WNT eta ad/or HODRLT QfAxGTS - - "-' with tlm opvadoe wM be billed m.az the addr ideffifml ahne`as.lb,A[I�UNr <br /> -4DDg=for tha site_ I also cm%dtaz a0 ivformarioe prod d an,tho apphotim a tree aed apart ad tbaz a0 rgehaed aeiri4e wL be perfwmaQ.-s ao®+daate with an <br /> appboble SANJOAQUC!COUNTY Or fi a Cedes anWw Staadards awd STATE ardor FMFRAL favus and Reealadoos as d ondm-Cmd oeoet,opcme,ora;;ieof the pmpv <br /> poshat the above facMty/sift adds I bwehp amhorm the rWL or avy ad all rm .md m+Ol a>$mm[ mform>aoe to SAN JOAQUIN COUN17Y <br /> 1-VII201'IVLE.YCe1L HE.iLTHDNL40N a sm a 2u arailaMe and az the nme Dme rt a FeovWed m me or my represmtm2 w <br /> f T <br /> {/� I - M E PRINT -» _ <br /> APPCANTNAM <br /> tJE `fV�6Al1 - X U-.1 SIGNATURE - -> °-r.�ai., <br /> s _ <br /> .n ' DRIVER'S UCENSE f <br /> TITLE <br />