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02/ 12/2006 10:15 209466343? EHD PAGE 02 <br /> DATE 3 Z b to MASTER FILE RECORD INFORMATION `TMFRrr GREEN FORM <br /> 6tleewvegteaaEtl W hmppa,X <br /> OWNER FILE UNIT IV <br /> COMP[ P OPE OWNER NORMATIONr 0100Ip OWNER CUnReyllyonpne <br /> PROPPATyOwNEn re'/r7/EHD <br /> NAME PHONE <br /> Foal - MI - fad <br /> BUSNNESS NaMnr�! // <br /> tae �- © S• •+m e.. _. •t-�,,.,�. - S0CSEC/TAXX0# <br /> Omer Home Addril <br /> Ll (l�all,n DRIIAR, LICENSIlII' <br /> city $TAI'S 0 A Q <br /> OwTrer MstlnaAdAte9d . �p l F 2 � .; <br /> MOiYng Address City <br /> 8tabe ZIP <br /> (*odbeTrnw❑ iNnMnleee.❑ DeoAl qdp❑ FAdmillni'mill tell <br /> IS HIM= <br /> •— <br /> ' gegyyr?± cin se ❑ M4w❑ <br /> 2s I a Nawsualness L=TroN not previously regulated bythe RNMealoill HEALTH DEPARTMENT?. VeS <br /> Is thle an EKISING SUSlnesS Lyes <br /> tuATYON bora NetvTwe ofregslaled Buslness4 - ❑ l`" <br /> BVSAI6S/FAm.tIY/Se18 NAMd <br /> No <br /> Fes.-I S O✓� el <br /> SktEAcoResS pp SUITE BUSINESS PNONB <br /> el <br /> CITY <br /> Ve'l 1111,1:1,11mig"I lille''1111 11 I'll,Nil III l ill! Ill, <br /> xill <br /> Mailing Address 1fDlFFSRENTIsvAo; /tyAdelsrss Attention:orcam gf(opHonap <br /> Mailing Address city <br /> STATE ZIP <br /> A <br /> HReD PARTY BILLINO INFO? Complete If'Billing Party lsdilfelfmm Property owner ol-Facllily operator/denUfedabove. <br /> g111311+Ess Naha <br /> t Attendon:orcaie of (Opdol <br /> .^d•, fart,RIA,`s,t �S k -7.e._c <br /> Mallirg Address PHONE <br /> a,Y "V st 1 Ill r C'^T — SYATBC & ZIP <br /> tI(`=WAT&AW for fees and charges OWNER FAdLM/BUSINE5S <br /> TtdRU PARTY BILLING <br /> Ll Alto 120,e-1 4=103511111GAlI,the undersell ApolloanU Amity time I am the Owner,Opererer or AuAaaslµed A l of the aushens,and I athnasvlcdge that All Pexx/rFear, <br /> euam -Zvmk'[asrFxrCIIAAOBBand/orgouALycffmaE armefared with this operadon will bobailed Ill aI the address Idendded Abel as thed0[drA'.7•Annaase <br /> hemndon provided an this APpdcadan Is Ill and correct and that all rgidufcd nedvfdes V4111 1110 porformed ra accordance wish W llcable Ate SAN JOAQUIN COUNTY Ordinance Codes aand/olr <br /> mdards and STATe and/or nDIIUL Laws and Regulation. At the I Ilds"l peri owner,aleordfor,or agent of the Properly]stated at the above 11691yft Addrose,I hercbr mdhorlre Na 1weure of <br /> f and so Mu la and environmental:h voir at lufarnmtan to SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DErARTill es anon As it it dvaaal and at the eaIn dAtstill <br /> Hdded to mor Lny represented% - <br /> Pr IAM PRINT <br /> ,PPLTt:JINT NAME �r <br /> l GIGNATURI <br /> v ..t.-a-f <br /> 1 L �✓7iA--- <br /> ITf.E. `ar-•O t m ' S T PRriER'S LICEN <br /> PNOTOGOW pEOLIAED <br /> i� p <br />