|
San Joy n COu+nt)(En pronrneRtal He
<br /> — — �K• ., 2!1! 'alth Depalvpnt J
<br /> DATe
<br /> MAIII STER FILE RECORD INFORMATION "MM-10 MEENII
<br /> �t�tt21tx4nl,r. OJvtik irk !.
<br /> > .: y NIT IV
<br /> I!:C�. ';�,:� ;, •',.I:,rk"I.-x',,11 � '
<br /> ... . :. .: .. ...... ,� .. ....,.a .,
<br /> OWNER F!A.E p O p
<br /> COMPLETQrNEFMOL WINQPROPERTYOWNER/NFORMAr/oN: emwr/rOWNER CuJ►ReMnronlo!"sernrEND
<br /> PROPG1rrvOvtNER NAarl
<br /> poom
<br /> r/rs► MI LAW ip
<br /> SWOL-,4n0 NAME
<br /> Sac
<br /> WIT-11)
<br /> Owner Nome Address 13p0
<br /> St I
<br /> v r» O �T Z DRwn,R'9LtCENseIw I
<br /> City CL z, -f 4'd✓ ' eTATR -I
<br /> Owner Wdfnroe
<br /> g Adde
<br /> V O
<br /> ..v
<br /> Mailing Address Ctb nn 11
<br /> /� be.l it sera Zip
<br /> QOnPOMTDI INnNUIDUp�� '
<br /> PARTNEpn1nP� �0 AGENCv13OTlIER
<br /> FACILITY PILE, - p,U
<br /> 1-70
<br /> tri' � •. :•.n:': ;�Ir;p: _ _ I
<br /> � 1f� [AIP h,hArt�,
<br /> �rN1�Y�, 1�� :i,'.[i�. :jFt�,.,;y�i'� r� •r:n;r.,h:.;�l.. ";'""i„1':'.:i�Ei'�"'il.='tire ���i: '1',;: rte::r, ..-u..,.�,.r..,}Plr:•.r: •.,o:�- ,.
<br /> � J,C,4.W, i
<br /> G. ;:�.: I,_eLlh',•,G„'� .rjieC`•� li''i'.,`..''i^.;:?.1_ �,,�� :...... ...:...nJ. ;�u'J':c:r',. :,r..
<br /> , „p, .-),. }, .,.y.n..:iii• _::�..•I�}r. ...;r��:r,�T �yr :,i;•, - -
<br /> ComPLErEmErottowlNc BUSINESS/FACILITY/SITE/NPoRpArlom
<br /> Is this a NEW Business LOCATION not previously rngubltted by the ENVIRONMENTAL HEALTH Oevr.4 'YES ❑ No
<br /> Is this an ExistNG Business LOCATION but ra NEW TYPE hof rogulatek TR� YES No 0
<br /> BuslNEstUFAO111TYBt1ENAME AAA TI, JC v•qS
<br /> t)rtEAoORGs. '0 Z Z F� SUITES BUe1NlMPkON!•
<br /> �f►/TAG f-_ z�
<br /> Orly n / v SrATP'�^� zr
<br /> r"�'.ea:ii I ' y "I':r s '•C';. Li r„' „I, .,.t.- o r;,l +0 ;; r,x•::ti- J
<br /> a•, i "I”[ u•:r ir' r 1r,rlk"r.Aylr,
<br /> �•.;. .a:'r. •�. .
<br /> a t�tS�k'f s;: II.T �f IS,:,�j L:' i,". I' I I7*;I n.y,S':.?+.. r Il'il7'Y' r;rRl•%,•.Si
<br /> r: .l r,:F• 5a! Ci +t ,i.ra.r •'i..it r11
<br /> MaIAngAddroanNdfFCRF.Hr0"rac+hWAddtmv ) C Anemron:or OEMOf(opdevatt)
<br /> 130e) 11,J45+11111,011aq Jy.;tt Z fifanct
<br /> Melling Address City y C.4 V 11) STAT; CA 211'
<br /> 1
<br /> _ ,,,,..J r ,.:r.,ra:q, '"'[::' I ":}I'i'f5i4y; !1!.I:.,:,rr;n•' "t;1?;' {a,• iF�,1 `"_f;!111':11 •4'd."• l.i I: i�
<br /> r- -•ik': ,I' '.� 1" f1'rn,.;t"tti�-t«Ivar ii. � ,r ;'�: ..f}•, rl'p,•�, ..I, y�. .�.:_,: .ii::�• _ :.E1 Iyy�� r�'3'
<br /> `:i:, 'aj:l.,ii7 �. 1'f i }} .J. .M;rk`, .l. �':•, 7t,: •�l:f•':i:'':.~:;: ,�'' i��:. Ib::r.,.lf.;A:'�I 1r�.,
<br /> r :I, ..A.:,al ra�:r '� ilii ,r-:� -I'';il"I:'., d 6NT.�..,•r: '.�:�;'.�1;.i.r:i'1i:';�'Fy.`;L."wla:�IL�d iaersd;,�.. �I' .-& r- 't�,.. :.::41. ��E6��'.:�'
<br /> �1 !r
<br /> ..,..:,.... :'. ''r.
<br /> RIQe�'�„ ..r.r 1¢�•, �,i; ,;F ,4::i,�i?`'�' I: •:I'r.. .I. r'I.: i:,+,. •t<:,:.IrlpJ,l.:,,, a, ,I "� P'F M.,:, r}'►t,:�•..: 5^•F:
<br /> y
<br /> THIRD PARTY BILLING ItlFot Complete lfollling Party Is different from Proporty Owner orFaclllty,Operator ldentt!iJed above.
<br /> I
<br /> BUaINlAR NAME ARonsi)llon:orCka eOf(OP&W
<br /> Mailing Addrose PHONE
<br /> I
<br /> crt5r STATE. zip I
<br /> AGCQlAfZlODD96s9 for fnon and cliaT9e9 OWNER FACILITYlB1131NE9s THtRO PARTY BILomro
<br /> BnLtnc�rm_Coans lANes ACUN0
<br /> Sv7
<br /> .EOGNjNT1 1,the undenlRsell A thn11•m Iba Otensr,0/,ANJmr,ever Aurhar5twl Agrott nt this Rtt,7t11ell,ead i aeteeoudcdRa That d1 AE>elnrl'I
<br /> P.CnH/.I1W.Er+TOAP6l/Ltir C16UtGbt nnJUnr IfOt111LYCfi01174t AmAnelnted with Iblt opmneRa vAII be Mlled to me nt III nOdrtw 1denODtd hbove Ae the ACCOVIN7An8RLitlet,twit slid.s III eersry that
<br /> All Infarmatibn provided ea this ek"Iknllork 1t true And correct;And lhnt nil relpllAedd aettddre will he perlhrmed to neeerdence with all uppscnble 3Ast.TnkAQ111N COV.WV Ordinance Cndrx andrnr
<br /> SandnrdA And STATE And/or FVCDAI.LANA,and RORVIAtlnnt-A■the underdilhad owner,rrperalM,or ARtat of the proptrlY IoaroA At rho ov AepBylute addiI l hereby nulhnei=e the release et
<br /> Any And Pill midis skied eavlroumnre"I ottex—out leformatMn to 9AN.TOAQT1rN C0IRPTY F NVIRONMEAtTAL 11fiALTH DEP At aeJse nt It is evaRAbtr tend at the flame lime It IA
<br /> provided Is ail or try representative.
<br /> _PLCAS PRIMT1 810NATURE
<br /> APPLICANT NAME W!, /A-/1/ ?Y 13 F i et b rte-
<br /> .nTtE ORNER'8 GIC£NSEat
<br /> �Aff:r-I A>�j1�. fe,vtrnrnev pwl7UtwPn1
<br /> Approved 111 nate Acaourib00McpPrp/MAInOCom IAtJede Dlte
<br />
|