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Sent Bye-: GEOCON CONSULTANTS; <br /> 1916 852 9132; Apr-8-02 3:21PM; Page 2/2 <br /> SAN JOAQUIN COUNTY • PUBLIC HEALTH SERVICES • ENVIRONMOAL HEALTH DIVISION <br /> FORM (EH M 1S(Ravwm 10102)86} <br /> DATE MASTERF1LE RECORD INFORMATION u <br /> gxenO dK _ 8wr�eR;IIYi i,... Clta>i g�-TrQI'Q 2 <br /> r• <br /> Y <br /> OWNER FILE <br /> CMECX IF OWNER CURRENTLY OJV FILE WJTllEHO <br /> COMPLETE T_NE FOLLOWING BUSINESS OWNER INFORMATION: _ _ _.......... �..�..... ... _ _. ___ <br /> Swu+eSSOw,ex - �- --- __..._ -i � 1---------� P>, <br /> r NAatrt ^-------." <br /> ---------- <br /> --_Fi±?2.._-•-----•---- -...—_hlL-- ---- --------- — <br /> ' ••---•- SOG SFS l Twx 1p� <br /> BuslMEsa NAME(If a meront Owner Noma) <br /> i ORIV4i'aLICENSE I i <br /> i <br /> Ow►eR HOME ADDRESS <br /> 3 �(� <br /> i i $TA ZIP �lj 4Ts <br /> i Ca" �^ <br /> i Atfanden orCatra of (OpBbrurl) <br /> i OwNeRMAIunaAuanpas NO/FFERENTb'romOwrmwAddnWr <br /> 3 <br /> 3251: ZIP <br /> i Ibm og Addrese UtY <br /> i <br /> 7tiIP>;OF OwNQ+a►sP- Fes AGENCY Qi'riER O <br /> CORPO"T1oW Q INp1VIat1AL 13PARTNERBNI 0 L Ac,ENL,I❑ CautuTv AGENCY[3 STATE AOlaNCY <br /> FACILITY FILE <br /> 7: 777= 3 l <br /> LI <br /> ...... i i,,.>•..,> ;,>,.r. .r >.CAos�i�ll�li3� : � > <br /> COMPLETE THE FOLLOW/NG BUSINESS FACILIT!�!1N!F!!0!RMA TION: <br /> Is this a New Business LOCATION or Vp1IcLE not Praviously rsgulnted by the ENVIRONiA�ENTAL H TH plvlaior� <br /> YES p No O <br /> Yli<a ❑ NO ❑ <br /> (a this an E�oBTINO Buaineea LocAT�oN but a NM TYPE of regulated Business 7 <br /> B AcatTM NAME(TIME e9E 71a NAM[ON HEALTH PCRMfT) <br /> wt. <br /> i SU(Yt# i BiJa7NE0a PHDIE <br /> foot/(,gtn'OW FOoo VEFOCLE LM.9 �'��___ADOREasI <br /> FAC3L=AmaEss(/FFAMTrMAA09M <br /> i <br /> i <br /> i ! i zfP <br /> Cr[rf #A fppplbrraaFOaoV�+ctEUSE <br /> i <br /> i <br /> :904i110 iktlSmG>.'.'; Afte,116n:Or Cans Of(quffa d) <br /> Melling Addrww ib+Ha+11h Arlt NDlFFEREVrfrwn faopifrAdtirass e <br /> i <br /> i i $TATE i Isr <br /> i <br /> Mailing Addnw CHy <br /> ;,... 3. i„r> 1:y r .,. r.7;r ♦ri .>f�.Tii 3�OFtlM.}IL'33. ;�'. -i. <br /> , <br /> is different from Business Owner Iden�ed a,(�ove <br /> . P _....._$_....�.rt . ....... ... .. ... W-� <br /> ............�....................-.....-.-- Y <br /> THIRD PART? BILLING INfOMtMAT10N'^CO�R7�^/Btf@,11�$Ill�ll Pa = A :�CW8a(aPd*KW1 <br /> SUMCS8 NAM <br /> PHONE <br /> MmIIWV Addrmm <br /> i <br /> • i SrA <br /> . Crtr <br /> for fees and chargee OWNER ❑ <br /> PACLITYISUSINM ❑ THIRD PART(BILLING <br /> AQQ2CI . <br /> ertify that I am the Owner, OPerator' <br /> BILLING AND CaMPI.lANCE ACKorktd <br /> Nt)WLEI>�rMPNT: I,the undersigned �NAt nrit,C ORCE,�Frv7 �� HOURLY CHa � <br /> Agent of this Business, and I acknowledge that all PrsRWT FEES, this <br /> associated with this operation will be billed tome at the address ideutifted above As the�ecou Dac vsrt e3 be performed n <br /> that all information provided on this application is true and correct; and that all regulated <br /> accordance with all applicable SAN JOAQUIN COLwTy Ordinance Codes and/or Standards and STATE and/or FEDERAL, Laws and <br /> Regulations. PLFAM PxtM <br /> APPLICANT NAME; <br /> SUl �. � gIGNATt,RE Q. <br /> ` DRIVER'S LICENSE.i <br /> TITLE Ar',}+ PHOTOCQ►'r REQVtA ED - -- <br /> .i:ppproved gY .::............ Aarauntli7gl(�flfc�pracsasingCampltedS�t �:r.......... <br />