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TAL HEALTH DIVISION <br /> FORM M"W'SIREVISED 10101N31 <br /> _ <br /> SAN JppOU1N COUNTY ! JDLIC HEALTH SERVICES • ENVIRONMF� <br /> MASTERFILE RECORD INFORMATION" <br /> DATE <br /> pYI1E0.1Dr / IO-/ <br /> �Hp SECTIONSFOREHOUS�r pyyNER FILE CIIEOR IF OWNER CiaxfFlnr°N FILE WI.IIERD ❑ . <br /> SA �/ 20 <br /> COMPLETE THE FOLLOWING.BUSINESSOWNER,INFORM N:..........----•-•— '._-............4__3-.._._..-�.......................... <br /> ,�//�{ <br /> I A,vv y <br /> --- - G 4 <br /> —^_ IT IDs <br /> G3Z <br /> ( <br /> ---- —III-- -- : soc SEC Aa <br /> NAME ' -----FnT— ...._....._......................_ : <br /> e ......................._..__...._........_.---....._ <br /> • to <br /> 9r,� i <br /> ' BD9INEs9 NAME(if d///.ren//rom Owne2Namel � Vv ' <br /> 7NK(;; s 1 rQ (�,T <br /> Zip �s376 <br /> i' DWMER Howe AUDRES!p O . aGX (O3 SIATE� �I <br /> ' r ty: l/ ( AtleR900:oream of <br /> Oes <br /> OIFF — s <br /> : (),WR MAKING ADRf96 <br /> Zip <br /> t state <br /> i <br /> i MaIII-9 Address City <br /> • TYPE OL pWNEP9I.P: <br /> FED AGENCY❑ OTHER LOCAL_AGENCY <br /> COIIMY AGENCY <br /> C3 STATE <br /> AGENCY❑ 13CORPORATION 13 INDIVIDUAL PARTNERSHIP❑ _. <br /> FACILITY FILE <br /> ...AC 6uNT 11)111 <br /> 7 CROSS REF H3 <br /> FACanr ID Y' YES ❑ No ❑ <br /> COMPLETETHE.FOLLOW/NG BUSINESS FACILITY INFORMATION'LE Tlol Previously IW <br /> regulated by the ENVIRONMENTAL HEALTH DS"M YES ❑ No ❑ <br /> Is this a NEW Business LOCATIOII or VEHIC ? <br /> wTYPE of regulated Business Z <br /> I,oils an EXISTING Business LOCATION but a HE <br /> I Buel,lesyrAca.I rHAw(Trsar I�s NAIrox HEAL�PERM � _ <br /> F-- F►/\ Suomi i BLWNEs9 PNarE <br /> fACILDY ACORE99(IF FAOILIrr IlAST09AE FOOoUMTORFOop VENLCL bEC fYM9 TADORE93) <br /> 'rrIORIN $, ZIP <br /> �: CITY/F FACKITYIlAMOBILE fC00 UMTOR Fooa VENOLE IpE�M�F 99ZtlTAL>°RE9s�lC 1T1 <br /> Lb KEY2 <br /> Loc:QIDN Cone <br /> KtM 6on") <br /> BOARD OP$DPE0.VI9UR DISTRICT <br /> AKenlion:or Care O((op <br /> Mailing Address{or Hasttlr Permit ifOIFFEREM/rom Facil/ty Addess <br /> STATE ! ZIP <br /> Melling Address City <br /> NO= C MMENT 1. <br /> APN! <br /> - . .. . .. . ........................ <br /> late if Billing Party is different from Business Owner /dentiTe a ave <br /> THIRD PARTY BILLING INFORMATION:..-CO/I/p.-...-•_„-„.................. ,A�rltlon:wCara Or (°PU°^al) <br /> SM,RE99 NAME i PfONE <br /> i <br /> Mailing Addressi LP <br /> STATE <br /> CITY <br /> FACILRY/BUSINESS ❑ <br /> THIRD PARTY BiLUNC' <br /> AGGQUN___TAt7QAEdS Or tees and charges OWNER- certify 4 erator,or Autkori' <br /> PENALTIES, ENFORCEMENT CHARGES and or HOU(tLr CUA <br /> it <br /> I;ILLING AND COMPLIANCE ACKNOWLEDGMENT: I, the undersigned Applicant, , ENthe 1 stn the (hinter, <br /> Agent of this Business, and I acknowledge that all a address <br /> dd T FEES, <br /> associated with this Operation will he biIICJ to me at tis he true,'rD identified <br /> odes so=[)RIVER'SLICENSE <br /> Standards and nd/orcovATADDRESS fur 11FEDERAt�Laws <br /> that a1I ice rrilation all a ro ahl SAN ed on JUAUI application <br /> COUNTY Ord and eorrdes Inregulatedactivities will he performs <br /> accordan <br /> Regulatiolls. PLEASE PRINT <br /> APPLICANT NAME Ol <br /> PI pTOCOrY REOra��y: <br /> TITLE D��r/� tared By.- <br /> / Del. Accounting CHI.,Procsssing Come <br /> • Approved 8 ZlA <br />