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r <br /> San Joaquin County Environmental Health Department <br /> V <br /> oA'E —1 O—C7 1 MASTER FILE RECORD INFORMATION "P-IFR" GREEN FORM <br /> o—=N" CA=0 UMO (T 1V <br /> cmvxm RID.L <br /> CcwxEm rmFoLLmYli sPROPERTYOWN ER lAwow,tirxW.• C/fficxar OMM cVfflMrrtravRx WMEHD <br /> ,,, tomyam- � o <br /> Fkst Mf Last <br /> L�, r <br /> 1=11V46 socaecITAXID6 <br /> Owner Heraaa Addroos 3 Dsnen'a LaceneA <br /> cnr 5 A; A-y,,, STA-M( ZP 9sto <br /> c+b scafm zip <br /> t ,tat O Ittotvtotiiu O. Pnttrrtytotrr{ F®AGO rO orn=O <br /> PACILM PILL <br /> FAanm►IDA 1 CM=REPtVV A0000MIDA Istwd <br /> COAPV—&TE7WFOLL(OPAW BUSINESS IFACILITYISITEAWOM+raTVW- <br /> Is thin o Ww Buobtcx Loc^yxm nod proviottsly rt VAMod by tho CtD/wt OW=WTAL WALTtt DEPr.? Yes O No <br /> is this an E osT nor BtaWscsa Locnrcm but a Nm Tfm of raVulCaMd Buainoas? Yrs O No <br /> BaCtLlfYlBtlll� �'In�J rtSYl '- � � �[—� <br /> Cm 2P 2-D <br /> ccW090pauscw0 osaystlor Kart ICW2::[ <br /> t& tpAddrwmo MDfrrfERIEJVThwnfewGyAdp4aw ANWr Jom or Ciro jgokk�tdJ <br /> 1 <br /> Addm=CCty rrvt SIA-CAZIP 5 5 <br /> Ar+`dA pq� 0 8 <br /> Tim=PAWT diLLiM 1XW- Complete Mi ing Party is diftrent from Proporty Owner orFt d ity Oper&W ident>fred above. <br /> Buateree blares �� /! AtdSrh"leea:orCar.O►(apGlorao'� / n��7� <br /> 36f 2- L s 5V--3- 2351 <br /> kVXPLffiMAgPffM totem mrd chmrg= OwNut FACKMMUMEss Tmm PARTY BD,i,.lw <br /> flnA.mtc AND Co rimct Acx"ow„y;vctllsNl1. 1,the ander sed App6km4 a oii tut ISO the CT~. or Aad*,edAEaat of Ibis)meets,and 1 adaowkdp that aD Prttsnr FM. <br /> PcEAW77,S E,VFOACF.itl'NT CHAJMn aaadl.►Afoum yCNARGPS astoci.td with tlhis openKoe willbe hZed to see■t the addrus isimtified■bale to the ACY'OUPTADDREfS for Ibis Nita I the amity that <br /> sY EJorowtion protidd nothis application is trst and comet and that all regWaled activities wail be perforated is aewrdanoe with all applinhle SAN JOAQUIN COWN Ordinance Coda sad/or <br /> SUMWWds and STA7t and/or FEn[ttAL Laws and ReVabbons. As the undersigned owner,operator.or matt of the properly located at the s e fasitltytn*address,l hereby arthorae of <br /> a y tad am rwdr rad wwitw,rseatJ aee■rrswt i■f■rwtiow to SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPART". ore it i.availsb4o a.d at ., it i. <br /> provided to amt or my representative <br /> APPLICAUTHAM 't ��Q. -� �..� ,�,.� t;IpNATVRe <br /> Tm-E E O�LV@R'8LICEp18EA <br /> App D.A. orie. b+ <br /> 29-02 10112/0" MASTER FILE RFCORD•GREEN <br />