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r • <br /> San Joaquin County Environmental Health Department <br /> DATE > �� MASTER FILE RECORD INFORMATION "MFR" GREEN FORM <br /> SHAGMAIMMRSIDW16M GA,ee UNIT IV <br /> OWNER FILA <br /> Cofitmm 7wEFOL4OWlNGPR0PERTY OWNER/NFOIMt47f w ONMNI,OWNEROuxwanrownzx r END <br /> PtmcsmOxxae Nam r�uCr S�fiPre tJtkty� 1MONr,'��,f�.�1(rt� 1. ''/1 <br /> AN Leal <br /> BWwme NAE. l,�tP1Ae. T'i ] . LLQ SxamITAxIDe <br /> oW Hemelddrees �'�� ®�J9 '�LKJ°'�� I 4 D."W....f <br /> M. taTATr �t 7JP �° L <br /> wmeru.Irms Maw �.� T� li-fii�tL g� �� <br /> Malfirq Addraae Cid z'P ( S Z.? <br /> COMDM11aN INrxJIouAL[] PARfNBRNV❑ Fm AaexOy� OtHea❑ <br /> FACILITY FILE <br /> kioiR,rgl�s_, �;� OPios'sjierro��:, iueauxrwa ° Ixyll '.: . <br /> CoMPLErE TNBFOLLowNG BUSINESS!FACII.ITYI SITE INFORminom, <br /> Is this a NEW Business LGCATKM notpv&usly regulated by the ENNRONmENTAL HEALTH DEP0 yes No <br /> Is Ods an E)MNO Buslness LGOATION buta NEWTYPa of regulated Business? Yee❑ NoX <br /> BUaxn&WAauIYI "N"e <br /> BrmAaowd Z �,� YV L>V 11.1 aures _,BuswEUPNws <br /> Llrf .811) .PCTuv\ arA.EL Siem <br /> BOAmoP(3ivaansbaUirmior t.neAnoxCooe KEH KE2 - <br /> MaargAddrfxu7•Dll4PRPMbomPaeyiyAddino AU.-d b:or Can Of(pphim4 <br /> ?As"Addr Ofty STATE Zip <br /> alOCaae APNe - O_ _ `_ Coaaem: -p <br /> THIRD PARTY <br /> �BILLING <br /> �INFO! Complete t/Billin/g Party is direrentfrom Property Owner orFaclllty Operator lden0aada�a^bove.n T <br /> BWNMNnxx d�[.)tY• 6._LI I�I.tl 'Z �.-ty/t'. Aaentlan:wean Of toptbw9 <br /> e <br /> Ma MPN <br /> Ndrwa hD3 L�wL :� r tz�t <br /> COY 6I ,/S; bYArcl^.i'L Cl.b�b�`( <br /> g2y torfeuandeharges OWNER FAcurylBusiNEss THIRDPARTYBwNG <br /> o Aad •'^ L&a mdvsfpred Appl(«n4«+ufy Poulam&e Oawn.OpeNa.wAadphdArafpr&b&ukm.avdledm,wledae 6ataY PDnarf3£S, <br /> p,NALT,Spavrt¢ep/4LkanMead/er H0 rCHAMa =odzkd with dhapen6mxB bebaed bmear&e addrmldnd4M.Iwrxn Wei fer Mkdfs I.ka«r6fy�n1 <br /> umr«m+do.pre.H.eoae�n.PPwsa.bwea,amr.«a.aadarm.yal,bda�loo..abepmu.m,aV.,«ma.,«wlro.v,ppcnwes.Niaew+rnmmo�ab.a«e>dr:mwro. . <br /> Smaud,,,d afaTe epNerFIDuuL Laws ud Rgaletlm+.AT&e mdrssimd aw,v..pu,w.or gmtef&a properyhntrd ea&e,bex 6dilyAib,ddrmA lYvebyea&prow&e rde,fe et <br /> my wd,p mu b and medro,u W e ..I bifarandm m SAN JOAQUIN COUNTY ENVMONM NrAL HEALTH DEP T'A�t/BKf/u/Ieeon/a//IL'6,/ruyL/'//J¢�Ia and'y.�1l&�.�unu dm.k k <br /> p Yerpreq repreambtire <br /> APPLI <br /> PetuePuxr / ! VV <br /> APPLICANT NAME <br /> TITLE y DRNER'9 LICENSE{ G [ /' 2 <br /> Apprand By Cam .4d L, O,b <br /> 2902 10MI MASH ME RELIDRGOREEN <br />