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r 7-20-19T-9 19T-9 3 04PI,l FPC"1 2 <br /> J <br /> -r.-„'d -r--•pc u+,'.. �,rr.. .,y,.p,�,r,.�.r r ;^ _ ar•« ..�.--.,-x,.� � •q.w L ,r <br /> 4 , �S�r� o�'�gcurt3�El���ty_x�:,h,+age'�_:;;_eal�t�r�SEr�rlees� En'itar�me���t �te�lti:�f?i�rislcn;y:.�.'° <br /> • <br /> DATEIL I <br /> MASTER FILE RECORD INFORMATION "MFR" GREEN FORM <br /> SMAOFOARrASFQREHDysEORLY r;., UNIT <br /> 'V <br /> V ■■■ <br /> DI D c 00 Q Q ff qU OWNER FILE <br /> COMPLETETHE'FoLLQW/NG PROPERTY OWNER INFORmArinN; CH6CXIF OWNER CVNREMTLYONF/LL•WTNEHD <br /> PROPERTY •T PHONE �/;y� CJ n <br /> OWNER NAME �Y��� N t. � L:;,' + ( ��� l�l• 1 �� t 1 <br /> i'Oxt Mf last <br /> BUslNeGs NAME SOC SSC I TAX ID# <br /> Owner Home Address DRIV£R's LICENse 9 <br /> City STATE ZfP <br /> Owr4r Mailing AdCrns n <br /> o 2 <br /> Mailing Address City ,- Stats ( r,+ Zip �Z <br /> CORPORATION INOIVIOUAL PARTNERSHIP FEDAGENCY OTHER <br /> Z�,� FACILITY FILE <br /> _ u77. _ <br /> COMPLETETHEFOLLOWING BUSINESS/FACILITY I SITE/NFoRMAwm- <br /> IS this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DIVISION 7 YES ❑ No <br /> Is this an UQSTING Business LOCATtoN but a NEW TYPE of regulated Business? YES NO <br /> Bust NESSIFAC1LITYISITE NAME <br /> 1 _�✓ �_1. � S 1 VA,L���.Mc�t L <br /> SITE ADDRESS <br /> � x BU I <br /> CL I -1A <br /> CRY �( 20S <br /> Tri Zip <br /> 7 . <br /> i�,� -7 ,-•�-_,7 <br /> Mailing Address ffOJFFERCAKfrom Fatsp/tyAdtrsss Attention:or Care Of(opbansf) <br /> I <br /> V, l ac: h•� ��P'f, ( <br /> Mailing Addreas City t . <br /> �-r/�. Li-1-� (.`STATE ZIP C( <br /> S1C`Cot� „ .. APN`iM f CoolM�ftf -. _ <br /> THIRD PARTY BILLING INFO: Complete if Billing Party is differeatfrom Property Owner or Facility Operator/dantifiedabove. <br /> BL*ixEss NAME ; ,A _ t� \ j �L, Attention:or Care Of (Opl%oRAI) <br /> IdailUtg Address <br /> } <br /> t��cd <br /> CITY STATE ZIP <br /> J l <br /> Lam' <br /> ccou�vr �s� for fees and charges OWNER FACILITY/BUSINESS TmRn PARTY BILLING <br /> BILLP.'fO.%tiD(.OMpLIANCEAc"OWLEDCML'NT: 1,the undersigm%4 Appltttlnt,tMifr that I am the Ow-ner,OpvaWr^or,lunharf7,cd Agee of this Ausfq�,&ad I llckn0WIcdzC that all <br /> PcnAnr, j—",P v4,r,,77r-%,&rFoRc4vaZ'T 0axcio andr'or ffovAr,YCmAKQG 1 associated with this'operation wiU k billal W me at the iddress idestiLed alfOVe as thi arrynE&s <br /> for this site I also certify that all Information provided on this appltcation is true and correct;and that all reguLtted Activities Will be performed in aiccordanee with all AVOicable SAN <br /> JoAQuri COt'MTY Ordinance Codes and/or Standards And SYATK And/or FEDEILIL Lslw+and ftulations. he undemigued ot1 n?r,Operator.or ugent of the property located at the <br /> ulx:ve facltitl/sitc addni.I hereby authorize the rdease of any and all results and enviranmcntal •nt information to SAN JOAQ(1r COUt\I-Y ENVIRONMENTAL. <br /> HEALTH DIVISION at soon as it is availuble and at the some:time it is provided to me or my reptwueta <br /> PLCA3t P'"MT <br /> APPLICANT NAME p , 7. <'i SI RE rM Cd <br /> TITLE 1 yp oRIVE CENSE# <br /> C,�u T V Z — <br /> F./tpprfS .3 7m.^ ,-.Dat ,L;.r�i:,t. <br />