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VISION <br /> E SAN JOAQUIN COUNTY OLIKIC I It At TN S( ICES • ENVIRoNVYAL HEALTH DI II (E1100(0400 <br /> 16ipevueo to/]IMa) <br /> DATE ` /O NIASTERFILE RECORD INFORMATION <br /> S'Kfo ecnoMS FOR E112 (fir St!i!!+ 11?1►'s teN N <br /> OWNER FILE <br /> r.-ocxw owNen cxmxrMTLYDNfit rw—ociln <br /> COMPLETE THE FOLLOW/NG BUSINESS OWNER INFORMATION. <br /> _ __..._.__. .. �.�__... ..w.. <br /> 8us1Ne3a Owrtw PTr�X <br /> NAW I-------�G 7( � --- --_. ---_— — </L� -------- <br /> FraT— —TII ' —CuT— i <br /> —____........ _. �..._ _ __. __ Soo aw I TAX 10 a i <br /> nt)SAW 11a Niue(If d/116ronf A•vmOwnvNune) <br /> STNV12)Vd �r �FiC �G =/z✓V �ftZ' <br /> l <br /> Ow..en I Ione Aooneaa <br /> Icity Z v 5 -/-,->Z U S I`- �J! !l I STAT! n Irf � 2� <br /> OWNER MAtuNG ADoaesa NDIFFEREN'*um OwwAddrres Attention:orCareof (opt/ons/J <br /> Stale 21p <br /> Walling Address City I <br /> i <br /> Tyre or Owraenarar: <br /> CORPORATION IN01V10t1Al_C] ER3HIF 11PARTNLocA}.AGENCY El COUNTY AGENCY C1STATE'AGL�Nc y❑ FED AGENCY❑ OT}IEn❑ <br /> FACILITY FILE <br /> (FAatLITY IC)� •Cnoss REF �.. <br /> :::: <br /> 1D <br /> COMPLETE THE.FOLLOWING BUSINESS FACILITY INFORMATION: <br /> Is nils a New tlualneea LOCATION or VEN1CLC not previously regulated by the ENvtnomwWAL 11e�uT►r l)rvrswN 7 YES 11 Na L7 <br /> Is oils an ExIsnNO Business LOCATION but a NewTYr'Q of regulated©uslnen 7 <br /> ' YES ❑ No ❑ <br /> a Lm Ne ae/FA.CIUTY NAMe(Tram WILL"nae II o+1 HEALTN PERMIT/ ,1 <br /> I DtAve I I Uuwru P�rrNc <br /> A.c:mvAooneas(/ff.. ).#A A166 food rowf� Vviactil L.Ae GoW --- <br /> l STATe 2+r I <br /> nO <br /> dTYIf uu►YrsAMoo"F000lAvirorr scxewe�ltl/I�AQYAnnxeuG <br /> 1pdi►itiitrCAlTli>i,ii :NCY1i �(lti2ii°° ii J <br /> :i 80ARd OH 9ik . .eok t]ivF4t.Ti4 i ii. .. <br /> Of <br /> Mailing Addrnsa Rx1{411hPwmO UDjFFERENTkwmF"k1y.4dantae Atte"go^'or Care (00Oa"/) <br /> �rAl! zw <br /> Mailing Address City ! <br /> APN a iit .fL?M11F'1f1<iil <br /> _ . <br /> THIRD PARTY BILLING INFORMAT1gN; cvmPlar,9 if Hlll�n Part /s dlf�'aranr 419./11 BUS, eo* Owner Ida/fU>7e —a_ove.- <br /> -- --._...._.....__.....................___ __ <br /> _ _.. ....... _._..._....... .__......... _ - <br /> �BualNcss NAue •AltelTttan:arCare Of (optional) <br /> Mailing Addreae <br /> I <br /> 1 aTAT1! Zlr <br /> CITY <br /> t�GRS1lYLtiQLllitil� for fees and charges .OWNf!R Q FACII.7TY/BUBINE615 Q TI*RD PARTY 13IL11tio <br /> BILLING AND CONirmANCACKNOWLEDGMENT; II the mitieroigned AIIp1IGIIIII,certify that I am the Owner, Operator, or Aurhor(ud <br /> F <br /> Agent of this Business, and I acknowled&c 111(11 All PXXVi/7' FEFS, PBN.II.TIk , ENFORCEMENT OrARGES and/or 110URLY 0LIRGEs <br /> associated with this operation will be billed to n10 At the address Identified allove Ar the dKcouNTADnmFss for this site. I also certify <br /> that all infonnntion provided on this gppliclllion is (nle and correct; 11111 that all regnlatcd activities will he performed In <br /> accordance with 1111 applic.IhIe SAN JOAQUIN COUNTY Ortllnuncc Codes 41111/or Standards an TATE and)or FLDLritAl. Laws and <br /> RcgTIl11Non�. <br /> �J T PLCA110 1`11`11Hr <br /> APPLICANT NAME ' /�� �f /J AIQNATURP <br /> 1 _ -- <br /> Id — <br /> /!//� �� gRIV�R'81-IOEN9E (S U(� <br /> TITLE �6.0- v!`e'se A' n rr ea g11eu <br /> . ........................................:....: .......... <br /> .11u...►:l6I.r..11..1l.11lq. . .. ...?IHr9fi ..:::.:::::.:.:..:.:.:.:.:.::..:.:............... <br /> 11IlEiE............... <br /> AP :: E.` .'•i' ?iii:? <br />