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11/08/2002 19:09 FAX 209 9480821 � 0 002 <br /> r i 191111 . 1 q � 7 smnnun autn <br /> ��>':n,��i�a�r., liil �,R���y��hy�•9'h� , �" �'�I�,; .yWd�w��n � ��: 'I °!"I�' <br /> dRFEN FOR <br /> flG�`FORMSATs MASTER FILE RECORD INMRmAnioN "MFR' <br /> y �L� 7 {� <br /> dwrewu.xwe�y ',4111 I 1 I'p1 I I ,;! le�t� UNIT 'Y <br /> wool/38 / owMeRFILE <br /> CoMP447EfHEroLLOWINCPROPERTY OWNER lNmRManev; cMKKJr OWNER cvxco. rPrmrf m EHe <br /> PAnr6[tTQwnan <br /> p„a.. (925)944-7209- �S' <br /> NAME <br /> !y'Y NI yy <br /> avail=NAnL DEL MONT[Pgolo9 SAcsec l TAa ID aM <br /> Ower Hone Adddeaf: ov[vea•p llrlas A <br /> CRY STAw <br /> oWlrer MdTop.dd 205 N.Wlget <br /> Meind[Adontst 51y Walnut i CA 'p 94598 <br /> TraE or <br /> CoAren wm Z INDIMUAL F.A�❑ Fee A01111M 0 OIN^t❑ <br /> FACILITY FILE <br /> �tis a1µ l OWN <br /> e f ! <br /> l�iiiLM I.,I{ �„ �IJY �18.t�lah, a <br /> Caffft BTHEfOLLOMIING BUSINESS / FAClfITY III SITE IMilemIAT74IN <br /> E lhLsd NLw eus)neu LOGReN not PmriM!dY re0elatrx Dy tllf EMVAnNMefraLNmLWDIPARTMOM TEs ❑ No R <br /> Ls Shk tln Elarroyc 61winaca IDGI <br /> of rngulaond Busine®? TGs ❑ No JI <br /> [wa+rss/FArntlr/STrENAMr D[L MaNTE PRapEltiT/FDR Rru.Waw pA�IT: <br /> Sm do 110 FT EoTST. Sunil# 61r9ir 1`1.104E NA <br /> Grow" STAT[CA 9bZdb <br /> i. <br /> fI b11.3. 1 A <br /> urr 4P.' !td oi"l'yI.�i.1 O <br /> i ! iy1� Li,1 ��fl <br /> .ia a 1 ,2lTIVANITS �al tE 11111 <br /> 1 1I �m. I 7 OtP in L <br /> Mai➢ng Addrrerr!/O)PF6REA7fmm 1'id6tyA40int s ACRfddMl ae Com Of f0pbibm l) <br /> Mailing Addr.ca CRy pp p pp qqryry p STATI 22P <br /> 'a o I u",aA'ti1 1'�nlN�l i' IFI',��I'Ilq�ylii i ill It'll t 1, '�� if twi CiIW i�I,4' 1�' VIII EII''�4hPM'lVll�l!���L'�Lt .f I �INKl15, Itd�, ,h Ell'l''..V141i�Nun . �it^ 4.fJ� <br /> '� , r'P;�IG' � �. • ,. , I � i l�f� r' ,� i'' ��Ei t �' nt h <br /> THIRD PARTY BILLING INFO- Comp/eteif Billing Parity &dhrerWtftm Property Owner or Facility Operator idw7t 9eCabove. <br /> Itun"Im NAM Atbortdam P Core of (Apoion,af)Ns.Ke//y Lys <br /> Meiling Address <br /> PNawr <br /> C� STAW yp <br /> for is"and charges OWNER FACILRY/BU3INEa5 THIRD PARTY 131LYNG <br /> BILuNC Ago C'OMVW,NM ACNNOTNLEDGMEW: L d.c,mdamir,rrl Appllotab CoddQ'ILpt I um 41,e OI WR,OPalnbr,er AnIAerQmi Ayry.r of Ma BYrllrad,And 1 nsbmwietAC tlmr an Pexern'Fccc <br /> PENAI.Y/Ib',BNM'MtCL9r€TGAAnlgermd/or HrNNLY CHAT =ngndueM NIM tbb nPCrpti.n Will 1,me hilled At me of The oddrau idwdliel rb,r *As the tJ22;IM'AUnx11k�'file rNp mm. I nlso m-dry dut <br /> all Infandadoa provided on&is aplditnden Y ova and anrrod-,And Ihnt nil fgWORd udvldo Wilt k pttf.rmed in Acw Hane with all.pplivIble SAN JOAQUIN COUNry V di...ve Code aAd/.r <br /> Stnndadda and 51'Atx md/nr pannML LAWI And Rarblplbnl, M Ihp undcmiq,M a.smr,epenlor.or.aeTt.FMo prvpotsy IA41W uT Iho nbrve fodliryhirc addres0.I herWry nnMorim Ma rvinr of <br /> any and all rtsplls nno vmeem f fuhrenado.,In 3AN.I()AgQlN COUNTY Kr4MROrlmrr4TAL HEALTH DEPARTMENT a.aeon as it ie a�ailaWrmJ„!eh,,$Aloe dmA it Ir <br /> provided m mear my Npraw lmbv <br /> APPLICANT NAME 1(ELEY Ls'Rof SIfiNATUR[ <br /> Tm[ E rlv I �o nrr—c.n"I'�I tva4 n(n C�r Ix(IveR•sLs�vse,s , <br /> (rneromnAlQUPIEP) - - <br /> IdII4, IIr,6dI <br /> Z00[a JNI2I33\IaN3 17ZSTO6 O�T9 IVP 6C:91 H11L Z0/6T/TT <br />