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��n �I rII <br /> San Joaquin County Environmental Health DepartmeiR����D�l YTII IL <br /> GATE GREEN FORM <br /> MASTER RECORD INFORMATION LEMFRtr <br /> SHADED AFIA%FOR Efil)UBE ONLY OWNERIDNyA oo !^ -QABBN UNI • IV <br /> _ {/ OWNER FILE <br /> COM NEFatLOWINOPROPEIR_TYOWNER/NFORMA770N.• cNecxvDwNER.cuxxEwrzroNpicewirREHD <br /> R <br /> AME L ... PHONErz;31_ !I <br /> nai Laot C916 �l S6-- V 4 O Q <br /> �oC).t, -r,L ro. n,_c �L.1su � � ONYERB LJCFNBEY <br /> STATE ZIP <br /> pwae�"lhp Addrcw y.yI J- IF( <br /> Melling Address Gly 5.1-0 L.koa-� elide CA, IIP q'6-2-O 3 <br /> CoRraunorl.❑ IxOMOUAI❑ PiRENFABH�P❑ FED ADPJ�cY❑ OTHEII❑ <br /> FACILITYFILE <br /> •FAD"ulil'.IDY CaDM REr IDN ]. ADCOdxr IDN IrM- <br /> ComptETErNEFOLLOw/NO:BUSINESS/FACILITY/SITE INFORMAnoN.• <br /> IB this a NEW Business LOCATION notprevIously regulated by the ENVIRONMENTAL HEALTH DEPT.? YEE ❑ ND;3- <br /> Is this an ExisTINO Business LOCATION testa NEw//TYPE Ofreguleted Businnerss? yes, ❑ NO X <br /> SUAINFeaIFAcISNENAME - Vima <br /> 'p <br /> C,fhr 33 Oz lett ' <br /> Birt AOprESe .fesw}I„ys("i Tr P.t Cr.�..� Tri-C'L o su EN BUNNEASPHOXs }+.` <br /> STATE CA ZIP <br /> :BIMnIidfBuiiRUt$oR 1)ariut.'f r -LOOATnNt%d0E' .: „KEH NtN2. <br /> Melling Address HO/AFEREMRwnFid*Addreaa fa,.v�.l. P-f (F W vel,! �} (.a:.Attentlon: Caro Of(opOawlJ <br /> Melling Address Olty - STATIM ZIP <br /> y61CCooe ,' /1PNN.�: <br /> THIRD PARTY BILLING INFOg Complete/!Billing Party is dlffemm'lrrom Property owner OrFacllily,Operator ldenbRedabove. <br /> BUMNESS NAME0+�.-rj Attention:OrCare Of f b;7nelf <br /> Ye rJ Y�I l e�.,.r� _ <br /> Malling Addrsa, t z...6 Mar <br /> STATE CA LP ((]Sj13 <br /> e.KA_nDgFA^fOrraDa and charges OWNER BILLINC ANDFACILRY/BUSINESS TNIRDPMTY BIWNO <br /> A rOTVE C Nr: le the undersigned Applicant,cabin that l em the Owners.OPerarar,or Audmnte✓A¢enl of this BmIn.s,aedl idnicatfedtethat 1111E FTAr. <br /> PrJu[Tial)gm pnepxmvlCj�I,tGEsantl/orNOracr6wcst'modeled with this quation wW be hWcd tome at the addrae Identified above w theAc'rormTAwREO'fdrmi,site.1 ubo ceit*IWt <br /> all In1arme8on provided-an thllappl[aHonis true end eorrecq and thatan regulated rtfidNes wUl be Performed Inaceordmce withall spplkoble,SAN JOAQVIR COuNry Ordleen,Cada Lndfor <br /> Standard,and STATE and/or LzmL Daweand ReguleHoea.As the undenigaad mvnab opentap oragento(lhe property touted at thubow fieDity/Liteaddmssl hereby Whorlee,the release of <br /> say end s3 Sulu and onvlreem en W nsasmad I'(ormado-to SAN JOAQUIN COUNTY and at the same Bane R L <br /> provided to me army rcpratlLtafift <br /> 7U ' `PLEASE PRINT <br /> APPLICANT NAME <br /> TITLE f,{�, P �� DRIVER'%LICENSEN <br /> <br /> ppplwetl ay OCsyp n Aeeeulltl 0111ee ProoeaNnp Cem elled\Bo'ns, Dada <br /> Z <br /> G <br /> l, xaZRfle re1L `� '6RN� Y��ro �V�f1.N b �6o4R�0(p —WWF��ys. MASTER E <br /> D, I t� <br /> �S4L 1S�d� � �� E �` 5�SP C�A iS fi � <br /> nV1�� c� <br />