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0 • k 46517 <br /> _ San Joaquin County Environmental Health Department <br /> DATE // f�rG MASTER FILE RECORD INFORMATION "MFR" GREENFORM <br /> $ Fa AREa_li EHDDS'SE O16T oaNEalw 10�O�1)-6J2 <br /> 1' C/44EP UNIT IV <br /> OWNER FILE <br /> COMPLETE TwFoaoswma PROPERTY OWNER/NFoRmAnot✓: CN£CNlF OWNER cuAlmWLrowFaeNrrN END <br /> PaoptgrrrOWt�A NAME �j,J nG r t� ..... PHaNE Gc—L1�j <br /> MI <br /> I2 ^ st <br /> rrsf Le <br /> Bdswpm NN /I " S 8oc 8EelTrxlDp <br /> V, I rl <br /> Donner Hane Address DatvER'e ucieneo <br /> city A 5 --.... STATE zip <br /> Dress Yanhp Addrou ��v. �� s�a j C� _{J, <br /> III Add.City ! .,, Saab /(/ f 7JP � ✓ SCJ' <br /> CDnPJMT10N INdyIWALO PAsrrNemxw❑ FmAc;w D Orxet� <br /> FACILITY FILE <br /> FACSJn IDS Fn 01�d1 CRosa REF 106 I Acoouln lDO 3 ("201 INN" 016 Q--2 5 0 <br /> C'ompt. YETN rolutoW7NG BUSINESS/FACILITY/SITE/NFORMATioN.' <br /> Is this a NEW Business LOCATION not previously regulated by the ENviRoNNENTAL HEALTH DEPT.? YES ❑ No <br /> Is this an EmnNG Dusiness LOCATION but a NEW TYPE of regtdeted Buslnese7 YES ❑ No fk1 <br /> Stirs ADDREss 9 �( Burne. BaaalEae PIgNE>aP�.4v�- .50U <br /> Cm STATE%f y Lp <br /> eoArtn DFStsrervteon 0vrascr Lo rwNOooe Keel 4 KEY2 tq <br /> €€ O <br /> Maliing Address HLYfFEREMfian fAcp/tyAdbem AtlnrtDon:a CIO Of(gvd6nNj 'f1M'�`r)�JJ <br /> Malllreg Addrasa City STATE zip vJ <br /> BIC CooE APN0 Casmrt: <br /> THIRD PARTY BILLING INFO: Complete i/Billing Party is different from Property Owner or Faclllty Operator ident(fiedabove. <br /> Owthmn NAatE J4(-17,Z A'tl �` P%�10Gi�{-�C'}! ABnnnon:or-Can,a(guell <br /> M.glr,g Addrees <br /> Cm STATE ZIP g36(. <br /> AC mWArl tew for fees and charges OWNER FACILITY/BUSINESS HIRCI PARTY BILLING <br /> Bat w AND Catpi.sin.Ar'9SUWl,Ercanvr: 1,the untlenlgned Applicant,tench lhal f em the Oxeer,Operaur,or Aurhon:.rd.4grnr of lib Sus n an acknowl ge that all PEunrFtEc, <br /> Pe setnrs.Es+oaCE M£sT bICRCGSand/ori/ot Rtr GLaRCEs associated olibtblsoperatbn will be billed to meet the address Mcnihneciabmeasthe A( oil xexr fo hH sbe. l also certlr'I that <br /> ell Inhrtmednn pros lded on this application Is true and correct:and that ell regulated activities will be performed In accordance with all eppllc.1,11 J DCn COC Ordinance Codes iloW.r <br /> Standards and S ren andf"FEaca,sL Law s and Reguladons. A,I he undersigned ow nee,opermor,or agent of the properts located at the above fat r! eait ess,I erebsSalience the release of <br /> am end all results and environmental assessnunt Information to SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT ash s ar able and at the came time It Is <br /> provided to nit or m?represemathe. <br /> APPLICANT NAME (? .). 7a"l! r z--E PRper SIGNATURE <br /> TITLE F <br /> Ad (Os�h�rt a� r (DpRHOTEDOr"REEQUffigo)# c.377 53 5 <br /> Approvatl nY Dob Accotmeng Canto processing Completed six I Deb <br /> 21).(12 10'12'6/ CONFID h E FILE RECORD-GREEN <br />