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RECEIVED <br /> San Joaquin County Environmental Health Department JUL 0 2 NIU <br /> DATE a 6 U MASTER FILE RECORD INFORMATION "MFR" EN,VII-RryU��i��lIVIUI[v��p'],1I/H(E�AALLTH <br /> ^�ae�ra rw „ OWNER IDS CASE* t�y� VSJ ICES <br /> OWNER FILE <br /> COAW.ETETHE FOLLCW/NGPROP ERTYOWNERlwomm77ow Cn s,OWNERCamrA rwvEyJa<N EHD❑ <br /> (1t- ftm 9'/9- PG3 -/37S <br /> BwaOS NAMe &o/-brau JTlJTE JCVELope;2S Z/u L aoeaee RA■rod <br /> Dwrr Hall.Ada... /8g52 /�/hc/YK.T71u2 G?ovA .S�a+->='e'u�/S O DwPeA�.LRSI.[aI <br /> C*j RV/,Vc STATE <br /> Omrrre.ap Ada... <br /> MYYhO AINrw Clly 8fate � <br /> Cony rm❑ INDINOGAL❑ PARTNF w❑ F®Aoea cv❑ 01MER❑ <br /> FACILITY FILE <br /> FAaunIDS CAOeBR"IDS AOooDNr IDS IN" <br /> COWLErE THEFOLLOM?NG BUSINESS/FACILITY/SITE A FFoIPAm nom• <br /> Is this a NEW Business LOCATIDN not previously regulated by the ENVIRONMENTAL HEALTH DEPT.? YE9 ❑ No ❑ <br /> Is this an Exm nND Business LOCATON but a NEW TYPE of regulated Business? YES ❑ No ❑ <br /> BUMN9eIFAtxurr/BMMN 5t(�FI/ 4 t/Jf" �-AQ.o1�ut;-- US <br /> shhenooRw SL,� /`.GAJ sums Bha1NhaRPh10NE <br /> Cm /,/c.f1GY I srATc C/� 7'r 9S 3 7 <br /> eT6atmwallwYaoADMnaDT LooAT10NC00e NM NM <br /> MW&v AdawM ftm FRcftAd *" AveAtbenlbn:or Cm Of/opd/agd/J <br /> yS 5• IL.AVLtrvL�'tDN AJAG `CNT(N/ <br /> MYiq Addrw CRy C.M/.,S DN <br /> STATE ('� 7Jr <br /> Bgoaue APNO DOePraer. <br /> THIRD FARTT OluuNa INiFo: Com/Iplete Billing Party is diTerent from Property Owner orFaeitly Operator rdeniTvdabove. <br /> Burrlat Huc CoV6STID&A- k)vbeS 4")q-s5o"j47t`is, Ir4c— AIc.Mlon:a cu.at •MJcFl3 ('64&ze'e- <br /> ralrwAaa.e. /9Ny9 /Z/v&IesA a1� �K Su e TG' 930 Ph 707- 935- YBS-C) <br /> " Cm So Al0("A STM M zip gSY7to <br /> dggaffrAaaBir for fSeS Wed Ghwg" OWNER FACILRYIBUSINESS THIRD PARTY BILLING <br /> BILLING ANO COAQUANR AClMOWLEDGMENT: 1,the undeniyved Apptiuel,cne(y Wat 1 am We Owno, <br /> epoubr,or Aaraorimd Axoar o1 Wu Botbeq and 1 aclmowkdge Wat ea PEAANy FeEs, <br /> P£llAf]SfS,ENNACEe£AT CNAEtEr and/or{lllllALYCMIMIES eaariehd with Mu openlim w,ll be b,Led b me el Ne nddrer idmM1rwd above n the ACYYNIMADDALfS for This fit, 1 she vedfy Wet <br /> A inrortm400 provided no this epPkation is nor end correct;end tbat all rerulaned ecdvitin win be performed in accordance with ell eppbeable SAN JOAQM COUNTY Ordioence Codes And/or <br /> Smndards end STATL and/or FEDERAL Laws end Rerylations. As the undmic t owner,opmmr,or arnt of We pnprrty l td at We above reeitity/sin adds l hneby eothor've the rdea of <br /> any-tad ell rnuln and w vinnmenml...t Information m SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT sone es it I,aYi od At We sea now it is <br /> provided to Dor any repreventamc 1 ,l <br /> APPLICAMTNAME `/E�,� A-,e.Je':/z PLuaEPWNr SIGNATURE <br /> TITLE l s/'C er c+ <br /> RV <br /> DRIVER'S LICENSED <br /> �1 V Iprnracaar neaNAEo) <br /> Ayproveds, I Dole Aeew.dNa Dllb. By D.I. <br /> 29-02 10/12/0; MASTER FILE RECORD-GREEN <br />