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'e-OCJ 08 '59 04: 15PM SEERSTIANI VINEYRRDS P.2/2 '. 4 <br /> RAN <br /> DATE 10 E3191 MASTER FILE RECORD INFORMATION FORM <br /> (EN OO SS(REV AEP 06N smT14 <br /> 0 <br /> UNIT IV <br /> OWNER FILE <br /> COMPLETE THE FOLLOWING BUSINESS OWNER INFORMA770M.- O.VeCKY OWNER OURR6 TLYOMP44mrHEWD <br /> .......................................................... <br /> auslk03 cjEBASTIANI <br /> VINE-MaDS <br /> 0a eja N"F ----------- <br /> .........................................fa-1---...............1, <br /> 0U91KFS5 NAME Of ddq;e~tftM owu,r Name) 300 sec I YM IDU <br /> i Owp&R Home AQQK%-U Ser-3 Fovxx" -5TRzv7- EAST <br /> STATE CA zip 954 7.6 <br /> 0Nw MmwmcAnmi;E= ffDIFFEWZXTftmOtwaerAdert <br /> Anbrition:&,r Care,of <br /> ER/GMA'Al 5 E)V <br /> Mailing Address City state <br /> Pr4omzuA6 13 PARTNERSHIP 0 Lct:ALAZFNcyM COuN AORNOV C3 STATE AGENCY El FCD ACENCY Cl OTHER 0 <br /> ]FACILITY FILE <br /> 112TRl:C4 <br /> C OwpLr=TE THIE Fo LL c wiNG BUSINESS I FACILITY I SITE/AFFO RMA 7/0M. <br /> ta}Tisa NEw Suai,Icaot LOCATION pat pr�;*,,Iy regulated by t,*EpmpcwkrMtAI-.4r:ALn 01VI310K 7 VPS ❑ Nox <br /> N <br /> 1-Ct*an EatismmG Buswn =LOCATION but a NEW TYPE of regulated Business 7 YLz No C: <br /> 5WSjNeS3JFA01U7Y/Sn-ENAME <br /> Tv2t4EF ROAD VtN'rr46'R5 WEST <br /> SITEAmDRESS <br /> SUITE# BUSWES3 PHONE <br /> WEST -rug IN GR. ROAD <br /> ' SCR ZJP <br /> m ailj,q Address"IFirEKEffr IPeoy Farv*AdIrmat, Al2- <br /> �Care Of jap6briao <br /> 5AMe- AS OW 00- JA,#J 5 64 <br /> Mating Addrena City STATE zip <br /> THIRD PARTY BILLING INFORMATION', COMPIfte if Billing Party is different from Business Owner Idendfledabove. <br /> ............................ <br /> Anentiors:or Caro Of (opr/ewtJ <br /> R=HESe NAME SwHW` <br /> AS NCR. ) FRIG N/4NS E711 <br /> Ma,knq Address = PHONE <br /> STATE ZIP <br /> CITY <br /> A cco (-8TA F_ss for fees and charges OWNER FAaLrry/BusINsss THuw PARTY BILLING <br /> PILL <br /> pMar F,,,,. prH nds. 0, e=and/or HoLmr QWG= a OwPd wh the operame will be baled to me at Me address lcinallca above as the AccOfZr <br /> AbDRUT for this sits. I also certitv that III allorwaLion provided an this apFlivIti.-6 tree Aad cerseq =d Lha ah rc%WwDd wrly om wal be performed in accvrdmce-ilb 211 <br /> le,,,ed ax the ab4" r2,Uityl,jee address_ I him6y Autherimw the relsax of any mJ jJJ rm-1 aad "vironnwnuij aueument jnfmnnaaioa to SAN JOAQUIN COUM <br /> F24VIRONMV4T,LI.lMkLTH DIVISION aa..za;%L,availab4 and%I the sknw time it 6 pnmidcd te w or my vvpreeelaeivc <br /> PLEASE PRINT <br /> APPLICANT NAME Egtc 1, HAW 5EV SIGNATURE F4k <br /> TITLE COMPLIANCE PROTECT- MANAGE DRIVER'S <br /> ls .. --u��,f <br />