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h1/Q2/2002 11: 09 2094683433 FIFTH FLOOR PAGE 04 <br /> � � ...�8 .y+rj5yi��vy��pp;L�yp��4;9^� i <x5; w4' '.a`32���y{ °��^q� "°se';-y' Rex' � � ,:��::� .��.'`�C..,...•. <br /> �kAt• , o] Y•.V..i�:`i RM{ ? ��1��.�.•�.Ai+i'T� � '�� �, � � kab <br /> "I•F!'p� FOAM (EH 0*151p*1"3e0 OSrt tii97) <br /> E MASTER FILE REGORDiN ORMATION <br /> :,.x. <br /> UNIT 1V <br /> � <br /> 4 f <br /> � .. . OWNER FILE <br /> 7'HEFOLLOWINGBUSINESSOWNER 1N-FO <br /> RNIATION,--- <br /> ^�� ..... CH6cK« DWNERCuRaFrvTcron�F►LEmmEHO^[❑ <br /> MPLa=TE »..--- W_.» <br /> .»...............•. __.__�....... �._...........•.._..---......—_1....__.....•- — t PHONE <br /> BUSINESS <br /> aver ».....,..».�_........!�?.,......�-----.._•_'--...........IR•71 - <br /> __. ...........-----�.... .._ .--_....... -- SocualTAMO V <br /> Is1NE5s NAME(it dhibre"f&am Owner ulama) <br /> - DRtVER'S LICENSED <br /> OvrNEp HONE Acion0s <br /> 197& <br /> ! S7ATi< ! zip <br /> 95 <br /> Altantion: OrCOre of (nybvr=# <br /> 0wraERMAILINGAppRESS (IforFFERFNT*vm v rweAdd—) <br /> i <br /> i State ZIP <br /> 1,,12111n9 Address City <br /> FIM AGENCf E3 OT1it R C3�OttPORATION C3IT401VIDUAL❑ PARI'rtmmp❑ LOCALAC&4=❑ Ct;uhrn' GENCY❑ STATE AGENCY d <br /> FACILITY FILE <br /> "' • a N <br /> OMPLETETHE FOC._OWING BUSINESS 1 FACILITY.I SITE/NFOR TfC?N.. <br /> Iafied 1tle ENYtR+7NMENTAL HEALTH DI kS10H.7. „ YES ❑ NO <br /> is Innis a NEw Business LOCATION not Previously regt� by YES Nv CI <br /> an FjtI5T1NG Business LOCA71oN but a NEW TYPE of retgt,latnd E3etarit Teas 7 <br /> to <br /> ,iE55lFACIlt1Ti51TENAME �a ]1 C <br /> - SUITE E ? BUSINESS PNOHB <br /> �1TE Apt1AE5S - ; 3 <br /> • - s - <br /> i STATE 1 ZIP <br /> trrY rQ C <br /> -�17'd. f �.x�iy :hies .� •r.y, � .`4:. 'rr '' '�1' � .. . .., <br /> ifD1 <br /> ss PPERENTffomFaeifrlyA E AtbGrttiotr <br /> Meifmg Addreor Care Q7(apLavt.adJ <br /> i <br /> ( 2 kR 1,j Ca� <br /> STATE i zap <br /> Mailing Address Clty <br /> NOR- <br /> ' ComPTete»..f. .Bl_llin Party is <br /> _r.e..f.t f.r�om..B.u...s..i.ne_ss` <br /> Wowner_�ldenti..f.e..d..a_brove. <br /> BILLING IT ORMA710N:f1tQPARTY <br /> ._.........r»_� <br /> Attention:Or-Care Of (apOiortaQ 4 <br /> BUSINESS NAME <br /> l Cert i <br /> i PtTt7NE g/(i - 0 3 1 <br /> "ling Address <br /> a V C <br /> WIC f A � 71Pp <br /> CITY <br /> F �S ZI <br /> �� for fees and charges OWNER <br /> FACILI TY/ 11SiNESS THIRD PARTY St <br /> es,acid I aelatdwledge that Bit <br /> SLLLVC COMPLTaMS , tg4OWLEDSr�LE`t`c 1,the undersigned Applicant,certify that I ata the ar.Operator.err anrkar� <br /> n <br /> ,EAWT FCES. p�fLtL7TJrs ENFOA(ZNTNf CKARc=andtor HOURLY CgAR=assatiatod with this pn-atloa wUl bo billed to me at the address identified above as the.;CLhofl�YT <br /> 1nMESS for this site. I also cenify that all inrormAda provided on this applico[ian is true and ctt and that all regulated ncsivities%rill he perlbnned in accordance with all <br /> a� .or agent of the propur.v <br /> r �31c S,►r.IoAQULy Cou,.m Ordinance Codes andlor Standuds and STATE andlor 1=EDkRAI Ly sand Re, As thr undersigned ranter,oto 5s 4 JOA USCI COUNTY <br /> at the above rwBirylsite address, I hereby authorize the roleasa of any and alk reset and enviroamental anessssment information to 5e1. Q <br /> aYVM0.N X*t4IAS.1�$,LLTH DIVISION as soon as it is available and at the anrne time i[i5 provided to me or my rcptnentative <br /> I 1 PLEASE PRINT <br /> APPLICANT NAME SIGNATUR 1 <br /> DRIVER'$LICI NSE# <br /> k TITLE � <br /> + t« rr �'t�Cy` <br /> t xY ; H4' r' •"' :xx :? `* � n � #Qt�ld4'�i .8... i.'.QF <br /> nr..i:'iiM, �ais:��ues:�k '9� t3atC�:S_ .°.'I',........:..:?. :fi'.�3 ..., <br />