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02/08/2006 09:37 FAX 12002/002 <br /> • • <br /> r <br /> San Joaquin County Environmental Health Department <br /> DAA ` <br /> 6 /p6 GREEN FORM <br /> MASTER FILE RECORD INFORMATION "MFR" <br /> e,,..e..,..........n....n.... OWNIAIDs vLlllxD►Y4[`j asEs UNIT IV <br /> OWNO4 MILE <br /> 4XWPLE7FTHfroLL0KTNGPRQPERTY OWNE 0941VP OWNER pace Yw Mf WrrN EHD <br /> Paine`^DW"aaN"e'e Gerry N Kamilos PRO. f9161 631-8840 <br /> Hrsl MI Leel <br /> Eu6wap Note SO[$¢/TAC ID a <br /> PCCP MaripDdd Lakes, LLC <br /> Owlter Home Addem DRlYe1lY LKafNa R <br /> MY STAR � <br /> ovro°r Malllm Addraas 11249 Gold Coun Coy Boulevard, Suite 190 <br /> MaIFI.Q Adds cloy Gold River ate CA TIP <br /> 95670 <br /> Np :nna® DenJv L2 PARV,Pa 17 fao44RKT❑ omen❑ <br /> FACILITY FILE <br /> FAmnr IDS I (r) J'►,o0 (ROSS PLO ID Y A=VIOa <br /> IE thls a NEW BuSUIESS LOCATION not preWDusty regulotld by the ENVIRONMENTAL HEALTH DEPARTMENT? Yue ® No ❑ <br /> I9 th1s an EJnMNs BaPMess LOCATION but a NEW TYPE of regulated Business? Yia ❑ No M <br /> Eo01N 5/FACT /SMNDN Mariposa Lakes Development <br /> Sore APmssa East of Hwy. 99, South of Hwy- 4, Weat of Kaiser Road, North ofmMaripo9ara R ads <br /> err Stockton STAR OA m <br /> BnoRn or SLnaY691t bEiNlCf 1 .1'Locoeni CR[ NE1'I Ner1 . <br /> mflin Addraw/fAVMRAwrN fadBryAdrws AR rldonr W Carl OF(A'JNanal) <br /> NaWna Address C4 Sum! m <br /> SC,lyes. 'APN <br /> TNIND PANTY BILUNG INPoI Cpp)ipWe 4`Billing Party is di1lPmnr hom Property Owner orFacilfty Operator identified above, <br /> eltsnJ6t NANI Al nadn:wCam Or(6,,VonJrf) <br /> Mamng Address p.0Nd <br /> Iry STAR Zoo <br /> ^'•for fees and charges QWNFR FACII IBLISINESS THIRD PARTY BILLING <br /> n....w.nn rnw••t�.w'r n scot mr..r . I,dr.wdenlLecd Applk•nt,cerng dwr I.�.rhe Ox•rn,O,rrvm,or AaNarL-ed Arenr o[Wu Bwlnae,AM 1 aWgakdpe rhes N PE.W/T Fisc, <br /> PalwttldS,YNRNY'ENEUS CN.IMJ6S and/or Nn+le[rL'JI,weR woclarcd vIW ddr op.nrbe aW be tlued to me•e dee addren Wendaed•hove ne the A(YnrMAnrurcv ler th6 rice i•I••eerbh rltar <br /> au <br /> anyIn•Pomen provNaeorcbeneunMInto nd eecWeJcOAll tUpuIW aedoHpednntmW,o.be.spenrr(oorvraNd purdMpsreptdlnne.nrcWtl etr6M.e•abpmpl'l<uNatlnaiSly./aefJRRRad4dmrra.WNereayOanu4trhaendnn Coad <br /> mncJennedefeore,unndupr»rSno •dSin VV tlReaudQoNOnd nHSAN CUNTY P <br /> P IRONMENTAL HEALTH DEPARTMENT sa own u It D avdlnbk nod at IN none dme k u <br /> prevldetl to me or ap reP •oraare <br /> APPLICANT NAME Punar PA9lr SIGNATURE Gerry Kamilos <br /> TITLE DRIVER"6 LICENSE A <br /> (rNDromEr utAtmavl <br /> Appered er Oen Aecatntltq ONlm Ero®IrN CernRlelsd sr OAee (p O <br /> 29-02-OO2 April 25.2003 <br />