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12DEC, 9. 20051, 1 : 00PM91666EN''"ONMENTAL SUPPORT & SERVICES N0. 2704 P. 2 02103 <br /> F���San J�atquin County Environmental Health Dtj=irtmPnti <br /> GREEN FORM <br /> DATE MASTER FILE RECORD INFORMATION '%kMFR'r <br /> St1aDLD.AttRI,V.6AF >! QwNCRIDiIt CASE <br /> OWNER FILE <br /> Ttr�FOLLo4vl�vGp OPERTY OWNER I, H, LO ( IR SB r f' owxeR euaae�l�nroNF,cFtvrr,�eltDt <br /> G xrN.pwtfFR NArte �c r t, _ _ 6 -— PHgNR 5�,�,7 ._. <br /> Flml Ml Law <br /> W <br /> co <br /> $cc SW/TAXID# <br /> RurtN�ss NAnfi �i Y 1�"C �� �'�� 1 � <br /> Owner Home Address T 1 e. S+r e e—t-- bxIV�R'R f icense# /" 1 <br /> � l <br /> city S CL 1 \ r � 5TAT��P <br /> oymer Malling Addr"s Q al L CcjQ q j o <br /> .� h1Z1R1ny Address Ciey d U `� SCtbe�^ ([{ ZlA �/_L. <br /> '1 <br /> T�.or_pt�eest»� <br /> J CoaPoMTZINEIMMALO PARTNeasrlp❑ F[DAG[NGY❑ OTNfA❑ <br /> FACILITY FILE <br /> "� CRo55 R&Ib S' <br /> TA-COUNT ID!F INV* <br /> FAaurr ID it <br /> Is this a NEIN Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPArlTMEPM Yrs yx? No ISI <br /> Is this an E1tXMNQ liusiness LocaTrox but a NeW TYPE Of TgUlated RuSlness7 Yes ❑ No <br /> 0t5INMjFAc1urr/S>;rE NAMD P Er e-K kirlctAqC GYl O,1 /r <br /> W SITE AMR= � /� �r e � k a eo a S At a ussiram PNONE <br /> cmSTA <br /> r-M1 e- riG k � oh1 T[/) /] Zm �^ J <br /> u BoAats w SuFmy SOA DISi:: I-LocurmN Coca =K"11 <br /> I�Q 7' J <br /> Mailing Address hfviFfrAmrrrow Fadlityaddrum Alf-rdlDn:nr Care of(optlonalf <br /> W <br /> Mailing Addles City SrAn Zro <br /> W SIC CDD[ APN�t 03MHCM <br /> THIRD PARTYDIL,L,INa INFOr CompielVif Billing Patty isdiHerentfi-omProperty Owner orl'acility Operator/dentiffedabom <br /> B,USLNt35NAM � ` Attentla�rCar9 QI' (OpH if <br /> Mailing Address 1 e �VC1y4�io PNONS <br /> Mn ZV <br /> Acrw rADOn=for Fees and chnrileg OWNER rACILITY/BUSINFSS THIRD PARTY BILLING <br /> u <br /> IdIl.LLY 1,die anrlenslgnorl AppIIcAM,cerll(Y Ihnt T am the mmncr.41ren+fnr,dr Abllmrfzrd Agrtnl of thin f3nainrs,4 and i ncknnwledPc thftl n!1 PEARIPFfillS, <br /> Par tI.OYR.r,6NFnACRM4nTCluactu And/or Bp(,A1y01ARgEs moocimed wi(A thL.operatlen will be blue(,to me At the Addrcat+Ident(Oc%t bovc a+the dCXLQZQRPAr=Me fist,clue- I Asa ccrfiry that <br /> All Informotloa pru"MO oa fhl,q Appllc•npa is to c•sld correct(rand shat,All rmCulated nedvitim will he perArmcd In acenrdRnct with nit nppticnble SAK,IOADWN COVNTY Ordlnrm,;e Cadres andhsr <br /> STAltdnrda And Srnrr:andfoT F'rnrRAI.LAw9 and Rettalntlona.As IN Im OMIgned 0+mgr.operntor,aragent of the prnperry lhanted At thnrrhfwc faeil1ty1Aitc Alldre r,1 hereby nntltnn'ae lho rtleut:of <br /> any Rltd 211 rcpultA and CTM1'Qasncn(RI AS1wr5mcnt 1pfumptiun to SAN.tOAQUTN COUNTY ENvIRONMr$NMAL.TIVAr,TR DEPARTMENT ns apon m I.b Allnble bed al the Dame Bine it l+ <br /> provWtvlmrncormyreprcnoatntivr. PLQwss <br /> PRINT <br /> APPLICANT NAME SIGNATURE <br /> W TMEry X1'7 —' ORLVEWS LICENSE <br /> t, `cit <br /> ' fPMD7uwrr asou[RnDI <br /> Approuee ey 0.yGs Accounting Oftlw Provming ComPlntad Dy dots <br /> 29.0^.002 April 25.20x1} J <br /> u <br />