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01-17-06: 11 :47AM: z 2/ 2 <br /> V_ ,, l r/ZVVIi Vd:2d hAX 002/002 <br /> San Joaquin County Environmental Health Department <br /> DATEF71 7"1 <br /> MASTER FILE RECORD INFO",&TION MFR`f GREEN FORM <br /> S�PU AREAS Mk owrNmrD# 6 !; 1 UNIT IV <br /> ON IM FILr <br /> MpLW1W,cFQU0WIN49PR0PERTY 04-- OWNER=*T*rr[roNmrNar EHO <br /> PnQvegty QN+NlL[NAJtt /�� `� C AaMe �O — 9�'f Cj r6 <br /> Flrsf All LASI / d <br /> BUSIMSS NAaeR T/ O N Aa Got QC/TAY 1p A <br /> e�-�� P <br /> Owner Home Addreae //7�?f � a /L pT P / D"It'S Wks t <br /> 0 (D <br /> city Z 4-7-/fofo/0 <br /> Owrw Halling AddresS a 3�o /� <br /> Mailing Address 4 /"/J{y 7 OD Sulu�/T 210 <br /> WpPoawn0la Q 1Ptorv�llA1(� GL <br /> PArrrr®.Pil► <br /> KD AOErtCY❑ VntER❑ <br /> { lwsA <br /> FACILITY RILE <br /> IDFAtnTrr # C\ xomREPlb gd AcLotJrrt ID tJ � �ItivJt J�.l <br /> sc <br /> Is this a New Busine=L=Tlom not prevlolWy regulated by the ENVM0xMgxrA4 HEALTH DEPARTMENT? yaa ❑ N.0 <br /> Is this an Ma5wNc Buwne=Wi wioa/buut a NffwTYPc of regul/anad Wsiitte", YES ❑ No <br /> 8v&NF55/FAaLrrr/SM NAr+l�C^J <br /> SM A <br /> STAT! /1/1 Z_ < <br /> BOAAD OF SUsIIVpBq PlyMeT LCCAriDN OOOf KM IQT2 L/7 <br /> Mailing AddJca ff0XPFff 9AVff JwMAQAQLkyAld*mw AtOen�on:Pr [o ff <br /> /1/O ��Jc/L lL / /� 7 <br /> MailirWAddr»cJty N rL STATE a► <br /> SiC COOS AYN S CtaaMQtr <br /> THIM P'MTY OILLWQ INFO: Carnplet,ff Billing Party fsdh7erentfmmproperty Owner orFacility Operator/den rvdabove. <br /> Dt1¢NF35 NAME Attantfon:arKt3ne or (opef 1w <br /> Hailing Addran9 <br /> QrY <br /> STwTt jm <br /> A=00 "z—Forfe and charges OWNER <br /> FACILITY/Bi131NE33 THIRD PARTY$ILLING <br /> G the andeni=oc,i w ry that t am the Owhar,Opoarnr,orAwk&*Pd Agear erthim s..lna%and I eeknQwk4Ec that all P&Wrr Fkzx, <br /> PEXALTW,ENPVR�CMkNwi'Ci¢kGgv and/or Nuuxt,T CIIAA=auoeiated,.;U.th;.ep"&t)_- I be beefed to me it Thr;add,-,id=t',fi d%bvrc ar Ne AcrnuNr A"bR1?cc hr yo n1Lr I also codify lha1 <br /> all inrormauoa providc4 on dtJa■ppllrytlon Ji true and corse and mar ill rciplawd ACU-itlee wW be performed In accordance with Ali applicable SAN JOAQOtN COVNxv O <br /> Sundardi and STATE an /Q)aana Cods and/or <br /> dror RDI[Pu Lawn and Iiezolalloar. AJ tho undenied ownu,operalOr.of a�bat o[me prvperty luvred al the above Aclhry/she addrv.,1 herrby puchdrizA Na releaat or <br /> any anQ N1 rraule.and esviroamrnW wmsnent mtom atlo.to 54N SOAQUIN COUNTY EYVIROlv�r PI-rAL HEALTH DEPARTMENT a■aaan it it II sWllible and al the mile <br /> provided ff mo Dr my rtpre�evtativ a ume it II <br /> APPLICANTNAM E� j y p �� PLE&¢PRINT 5t(�?i►ruRE v'— <br /> TITLE `'����•�• DRIVERS LICENSE s ��,�� <br /> fwlctemrKaaownml �f)� l?j �"' <br /> AGprwaG By OaOa A=uRdnp O'Rk:O PIft0Wn0 C0mPaRad By Dann <br /> 29-0:-003 Apnil 25,2003 <br /> CONFIDENTIAL <br />