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rn �� <br /> ' San Joaquin County Environmental Health Department GFYEEN FdizM <br /> DATE 6 ( MASTER FILE RECORD INFORMATION "MFR" UNIT IV <br /> owmM ID# <br /> CASE* <br /> S" <br /> OYYNER FILE CHECKa OWNER C'OEEEa,,,,ON aEAnN END ED <br /> NER JMFORMarroN: ROM <br /> COMPLt7F7NFfOl1OWlI�GP PE )) /f <br /> P0.oPERfYpwNERNMtE cC <br /> LL(f, <br /> Ml Last <br /> First r�IT_ !.+/� <br /> I � SOC SEc/7AxI # c V V U <br /> gusmF55 NAME C.C' C�2! C'I .0 f'LC�w� s <br /> DR1YE0.'$r rrsxc# <br /> Owmer Htxne Address <br /> STATEA- <br /> Crtr <br /> Ovaser Mailing Address 2- 2 I ,> <br /> Stare � r+p s Z Z <br /> Mailing Address CRY �.C\Y <br /> CamoaArroM❑ InorvmuAL❑ <br /> VArtinEPST®W PMAW�❑ ❑ <br /> FACILITY FILE <br /> Inv# <br /> FAaEm ID# <br /> C0.0ss Res ID# paouNr ID'# <br /> Is this a NEW Business LOCATION not pmvioLL jy regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? Yes ❑ <br /> Is this an ExtsrlriG Business LOCATION but as/NEW TYPE regulated Bpslness7 <br /> BtE,alE5s/FAtam/SrrE NAME ///'7 �iemsl$+-S c,, <br /> SMADPRESS Z �., C CIYlpY VV A ( (T'?r� lO�l /O'✓s Sime# 6uszip <br /> E72 <br /> MA67d�JfDffF�ft= <br /> fo6k 4?;�7 <br /> ,sm,Q wrw,-roNRetzD 6OX� � . Attanta)a:or Care Of(optlwP)FFEREYrhan/Fad/Ky.ddd+ts {1./ V7 iVTSTATE �( (( <br /> above <br /> THIRD PARTY B161rNo INFO: Complete if Billing Party is different from property Owner otII Facility operator identified • <br /> .( la <br /> Alt�ftlort:O cane Of (apeb /J) Q <br /> BIISWESS NAME -��/I S As so ;/i�..la- PHONE g � / � / /2i <br /> Mailing Address /�/, �f /✓� ZC..� (� / <br /> /, STATE ZooT <br /> Cm .y, CA <br /> ,.,.Ann_Ke'fd+tees and charges OWNER <br /> FAC6ITY/13USINE S HIRD PART'BILLING <br /> ACLW <br /> P I'll, wt rtr.MESL: 1,Nr uodeniped APPac Certify that i vm Ne oewer,operobr,or Autharfud Agent of this Rnsincv,and I acimowkdge Net W P,certify that <br /> t' for da, <br /> site 1 aBo certify that <br /> ACPASEA'f CE.tF:av'atM/ar ROURGY CHARGES assoriated with tau opendon will ae baled to tce at the address idebdded above u the dL1'Ytjo,,Q Co <br /> r�Y.v.nas.ENs'd <br /> a. As the undersigned Dover,oltcabr,or agent of the property lonlzd et the shove btilitylite vddreas,i hereby vuthotire the M—of <br /> oU information Provided on NL vpPlioeao u wv and correct; <br /> and Nat vH regulated scavifin will be performed a aeordanrk with ell apPtirnble SAN]oAQIDN COUNIY Otdlvvvn n or <br /> Snnandda Ind olts a aolpar p7♦IgR to L+s anti ,inia <br /> any end VI rnuin and eevitn®evni ememmrnt informafiov to SAN IOAOUQi COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is avagabl�d at Ne same time it is <br /> provided n me or my represevAtive, Pawn SIGNATURE <br /> APPLICANT NAME L <br /> DRIVER'S LICENSE# <br /> V <br /> TITLE . p _ (vl+oTsxovY aEWmml 7�,J <br /> V Date <br /> Apyruvm a" Dam ACcwnting Dare Ptnrotsing Corrtpland BY <br /> 2942-002 Apn125,2003 • • <br />