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PUBLIC HEALTH SERVICES • ENV ."MENTAL RE' ALTH DIVISION <br /> SAN JOAQUIN CUUY.. FORM (I:H0016(REMBEo 1U/91181, <br /> I <br /> DATak :L MASTF-12FIL.E RECURD INFORIVIAr1oN d._ <br /> i inFnl aIbK41 <br /> S (I <br /> OWNER <br /> FILL■''^ ^ FILL C"tax tF OWNtFt CyRREN tLYan F/LE rY1tN�Nl] 1 <br /> CoM .............. I <br /> BtIBlate•t7v+�a - <br /> N � � S� 0 89 <br /> _.....M.................._.._....., � SOCSECIIAx <br /> Ib>r <br /> ..Bue1NL9A NAMEi tT d/lffansnt frvmC�+ner Nnnre) ---. _ ---. . <br /> OWNER t1oME Aamuss 1 Li <br /> to o G S _ <br /> Zip <br /> E=Fw <br /> EG—&—:ro: . 4 7 ) <br /> AttenUan:orCare ot (upt/un.+l) <br /> OwRER1lAuua!Aooaess ypIFF£RENTfrvm ne�rAd R r N n ; !�12-IJ bS `- l YLC)TMato k, – <br /> 1� 1�. <br /> i{p <br /> tdalllnp!Addross city /9 G 11 O - <br /> d 1u <br /> Tree cu CwNeaetsr: <br /> (�pRpoltATtON INDIVIDUAL f� PAfiTNERS+iIp U LUcnI.ADENGr LI CQUNIY oFNGY U� S TAT E Ac NGY U FED AGENCY D bI heR L <br /> FACILITY FILE <br /> -0 % <br /> _ .hcaouFlr ID' <br /> -- -- <br /> COMPLETE TNE.FOI.LOW/NG BUSINESSFACILITY INFORMATION' <br /> is this a New Business LOCATION or VF-mcLE not previously regulated by the kNVIRONMFNTAI HEnIT'N Drvlstuw T Yes 0 No <br /> Is Wei an EbsTuro Business LOCATION but o NewTvre of regulated businosa <br /> guarce&,FAclurrNAMEtT"awou i,erwNAmtumHF-ALiliK1` Ml() <br /> BuslNCas PHo►tE <br /> FAoa►T�Adoattrs(1cf�cvurrtaAMosr[�taaoUAvratFn�wVv+c�eusr�cl���naY,AudNt:s�1� <br /> I <br /> drYI�FACKerr'rsAMoe/LEroaau,roaFowV GLEcmQgmml atAnnHt63GIYJ 8rG ^ <br /> i4til /7- _d <br /> i�outn br s�txr�vi�t;a tk�Yai�r � !.'�P.��•+ ��'Kent �it<� . <, <br /> Ationtion:or Care Of(optional) <br /> alllnaiAddnuss fW I•f4llflti perm/l ND1FFrRENTftM Faell/tyAdd. <br /> (tt <br /> . .� - ....-_—_--- ._�•_'—__-- � STATL IJP <br /> MAilinglAddress City <br /> APN Mt 64,W-tr <br /> BIC�yoE i .. ,. , <br /> THIRD!PARTY_BILLING INFORMATION; Complete!f Bitting P rk l is d/lYerent from BUsir►eS0 Owner Identlfled abovN <br /> . . ....i... .a n Alttentlan:orWreOf (opllanal) <br /> euvoegs NAME <br /> �l.✓t tl�- _ L f! ^lin. /K tsA rM - <br /> 1 ( _ <br /> MaiiingAddrau T.,------ CEJ <br /> ti I <br /> { 8jA,4 k ���1l1 oCITY � <br /> (iVc, Ci�-sQ <br /> -A 1XQ <br /> p . <br /> 1(yT,gp9ffEj9 for tees and charges OWNER ❑ FACILITY/BUSINESS i l THIRD PARTY 1311.UNG <br /> BILLING AND!CONIPLIANCE ACW49YY EbL"M1i>*NT: I, the undersigned Applicant, ceriifv tha# I afn the Owner, Operator, or rtu(llori <br /> Agent bf this Business, rind I acknowledge that ali PERMIT FEES, PFNALTIES, LNr,01?CEA1ENT Clrtxc!✓.S and/or- I U ICIIAfIt <br /> associr„cd with this operation will be Milled to tree at ihC ;. l;lress Identified above 2s the AcC�t1;;riDb.4F;S for ttli$site. I also cer <br /> that all information provided on this application is tt-;Ic and correct; And that all regul;lted activities will he performetii <br /> accordance with all applicable SAN JOAQUIN COUN'rY OrdillancC Codes null/or Standards and STATE and/or FLl)C{tnt Late; <br /> Rcgulaitons. <br /> PLEA11C PIUNt <br /> APPLIqIANT NAME Y*� G. 15 A) <br /> 1 o rel A S <br /> tilllvclta t u;rNnr k <br /> TITLE I G 4=1N !t") 0 %/ i'Itultx: tl r,te:uul trtt) Q ���.Y S <br /> A�ovUnUn t7tfi�tr Proao�Irind Gamp►atRd pX . r <br /> y ;:..:;., �21It <br /> Appy d ey:�>..,.•::>: :...:... ....Q .. :,r:.. .:.. .:. <br /> s� <br />