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APR 26 104 16:2B FR INT RAW MAT*PORT T4 503 286 8716 TO 12099314606 P.03iO3 <br /> ( � SAN JOAQUIN COONTV PUBLJG HEALTH SERVICES s EN.VIROMME_ HEALTH DIVISION <br /> Mau (Ef1m16t11svlse•loratAs) <br /> DATE MASTERFILE'RECORD INFORMA r <br /> 6urtr rvz�l <br /> OVYN1ER FILE <br /> L43 LT <br /> COMPLETE TNEJF0LL0W1AfG BUSINESS OWNER /JVFORMATION: Goeow,r OWNER CkmgewnrQwf1LEwvnfEN0 <br /> _...._....._....__.. <br /> ........... <br /> ............... .. .. <br /> ... ..........._... ..._....._...,_......... .. ......................................... <br /> .. ..._........_._.._._.... --.._.._.._....------...�..._.. <br /> �8usI/TEsr OrrrTcn � I <br /> I <br /> NAME I ! <br /> --------jyT�—J—.- -- —�—�_. ____-.--�S7.---- ----, 1.� q <br /> �~ I Sot Oft I TSR 101 <br /> I S{(alMraa Nwre(11 ep/rerenf Aom .� <br /> 1 Ow1EwP1aMEA0oNlsa / _� <br /> I '�� Q[ /� <br /> i ay, .a�^ fig <br /> L Zr KA]7 <br /> OwwEn Mwiuls ArxTnEas N/1IFFEAEiVTAvre Oowe►Addrwa { AtteeUen:orCare of (opl/wul/ <br /> i <br /> i <br /> Malling Address City Bible f Zip <br /> TME OF Ownepalsr: <br /> CORPORAYIDN❑ I140144110UAl PARTNERSHIP 0 LOCAL A 0 CoUMrT AGMCV C1 sTAYE AGENCY 0 FED AG&MV-0 OTHER C] <br /> FACILITY FILE <br /> •:.,, gD • <br /> �•� t ITva .:: ::„:rY::�tsasl>:�irXAl=:i '::.ACCouHf`Iy�l ii;; <br /> COMPLETE THE.FOLLOWING BUSINESS FACILITY /NFomwnoN. <br /> Is this a NEW Business LocATom or VE►IIcLE not previouaty regulated by the ENVwoNMENTAL HEALTII DIVISION 7 Yes ❑ <br /> Is dile Rn F1ur me Business LOCATION but a NEwTYPe ctregulated Business 7 Yrs C NO <br /> 8_ �Fwautr Are <br /> (T,"14LL sc TW N^W 90 HEALTH PER T) <br /> FA AaonEsa/>KFA ►IIIA MCTee. fArrouri e � SurTTas ; Buslaesa PlallE ''//��. <br /> I II ( 9el- T7 {{{I <br /> aT�s`F•AOlrnaA MbeNE FOWIIAVTOTT FOoO IMeutuoE�ijAQrAnfllleas C,ir/ w Z,P <br /> I .9 P+�E1Mt' Irk►�±DItm1 a e.t t `: ::i;: 1(Ii►7'' `K `+ '': <br /> Mallin Address lBrJY0Ah Pern,N JTQMFEREMA-Om FwoW0,Addiese i Anenllon:or Care of fvvons/� i <br /> i 0 SS <br /> IIMnM.AAIrs••Qy i srAos 9 Sz�Z <br /> , <br /> �� � � >!A►}N'Jk'!i; �'COMMENT; <br /> Blip <br /> TNtito PARTY BILLING INFORMATION: Complete i/Billing Party Is diKeretit from Business Owner IdegNred above. <br /> ............._..............._............................... ._... A _................ ...,.... ... <br /> I Busumms NANO Anondon:or tare ( (opNons1) f <br /> I f 06 4 1 Tri rA r i <br /> 04e1nnp Address <br /> qtr <br /> i �E ri am <br /> I zw V I <br /> A <br /> �'�t/Nl'ApARE$g for fees and charges OWNER ❑ FACIUTYIBuswESs ❑ Tliltto PARTY B LuN <br /> BILI,INC AND COMPLIAN07_A(I:Now1xDcMIiN1: I, the undersigned ApplicAut,certify that 1 am file (Ironer, npe►alor,'Dr Authorized <br /> Arent or this Business, and I acknowledge that All PEIN•rrT Fecy, PENALY7ES, eP1F01tCev/EN7 CKA11mrY and/or HOURLY C//AR(;&r <br /> Associated%vith this operation will be Milled to nil'at the address idoillfiCd above Air floe AccomyrAnliRICSs For this site. I alsu certify <br /> that all informsation provided on this applic:Itiou is true and Lorrect; and that all rebuhllcd aclivitics will lit perrurnled in <br /> Accordance with All Applicable SAN JOAQIII14 COUNTY Ordinance Codes andAir Rntlards and STAT' jidler Fu>laim. Lsm and <br /> Rcgldatiuns. <br /> • PIEwsE PRlwt ///111 <br /> APPLICANT NAME I Ay f� .M e etc E -BIONgTU1tE <br /> TITLE DW N e2 DRIVER'S LICEN3E I <br /> rilOTO6o►T RETxNnEn V 2S <br /> • ,X: :t:..«s:)g;,,:•,:SR .D1111I�:.. -• :::-. .P ,Ili fi7 s G/' imp�l :••a.;. ... '��• <br /> APR 26 '04 15:51 209 94ROK71 PAI:C MID <br /> ** TOTAL PAGE.03 ** <br />