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Tn Run <br /> bNa!ti I r "Ea12[ Div sin a��dl <br /> r A:m QZ"d lEN Oo ss(R(.ysa[a nrnAM:. <br /> ' ' Q I ASTER FILE RECORD INFORMATION FOAM <br /> �usaea.�aeetemtf„o�•o»� UNIT IV <br /> OWNER FILE <br /> ..bMPLETE TW FOLLOWING BUSINESS OWNER INFORMAT70N.- CHCOM IA OWNER CuaaE mr on r/Le witTr@ttD j <br /> ........,_w........... _...... -- `---'-.._................. .. — ...- .__....— — - ......_.....,. ._.._....__.... <br /> 5L'atN£S9 ' I�f ` V•\h� --TI�aY}A PHONE <br /> l t <br /> r- <br /> fIIVNERNAME <br /> . _.........._.................---...-....,_____!IY'--.._'_...„... .....M.u....-...........,.,......._............ <br /> 1x1___.....`_...._....—.....-..i._.___ ... ..._.. ... <br /> vsvass NAME(d dlTerent from Owner Name`) SOc SEC I TAx lO• <br /> nYNER HOME AOORESa <br /> � *PL't 1 <br /> �SawZ, 6� 1A VtL0. VCA i (,7 �y( <br /> LP l�1..0_.-I+.�.___._ <br /> ,wHXRMMLINOACZAM (ff01 FERENTfromoemerAddreu) 1 Attention: or Care of (optional) <br /> ruoing Address CIry �AW P.. U.il LI�Dt�_ - _--� -. - ' State ? Zip --- <br /> ;:R?ORAYION❑ INPIVIEUALK PARTNERSHIP❑ LOCAL At:eN 13 COUNTY AOENs:Y C7 STATE AOSNCYO Feu AGENCTQ OTHERr- <br /> FACILITYFILE <br /> _OMPLETETHEFOLLOWING BUSINESS I FACILITY 1 SITE INFORMATION.: <br /> this a NEW Suwineas LOCATION not previously regulated by the ENvIRONMENTAL HEALTH OnnstON? YEs i7 <br /> r irds an E%IsTINe Business Lo nDN buts NEW TYPE of regulated Business 7 y YES.q_u`_, <br /> 'ISU.::it/FAOIUTY/SrTr NAM& t1 1 p <br /> IF AVOREss ' . 1 SUITES BWINESSPHONR <br /> STAIE,, z1P <br /> va <br /> �•atdino Address ifD1FFERENT7om Fac/11fyAddmS Attention:or Caro Of(Opb'Onal) <br /> 10(05 �7J�S� �1Kyoi VL- <br /> ;ui.ng Address Cify �a STA ' ZIP Ct S 3 <br /> HIRD PARTY BILLING INFORMATION; Camplete if Gitlin$ Path+ isddFerentSomBusiness Owner Identified above. <br /> .,,...._.._.__......__.___-......._"--'__-....__-......................_._._.._.....—............ ... ._......, .......y.......»..._.............._........_....._......._._.._......-......__.........._.._...... <br /> .vs:Ngss NAM£ ! Attention:ar Care Of (vpr7onaf) <br /> 1 <br /> •A�iing Addre95 1 PHONE <br /> STATE TIP <br /> 42g,T !1 am for fees and char US OWNER FAciuTYISUSINESS THIRD PARTY Bll•UNG <br /> [VGAND CoNtrLtAFCCAt�oIowLcao�ip�v't: L the undersigned Applicant cuti¢that IAanthe owna.opaefor,or.4uthodudApemefthis aesineuL2061Acknoakkdgetbat.,�. <br /> I+Vr FEES.PLvu77ef.Bt+fORCEHEnTGuROES and/or HOMY CNIX&Associated with this operation win be billed to one at the►ddmi identified above as the ACCOL1vIrSJIdRr_s <br /> thv site I also certify that all information provided on this Appiiation b trut and earrzct and that all regulated activities*1111 be perromsed to 4ecordAnee with all spplighb�;.• <br /> cOULv COVNTY Ordinance Codes and/or Sandatdl And STATE and/or Ft lAxL EArs and Reruhtlom. As the uadetsignrd o*1oer.ovorstor•or ageot ortbr property located at:kr <br /> •.t radltty/ake addrsss. I he.aby aurboriae the raieaae of any Red aU ttsnlb and environlnmtal araeamane tarormarios to SAN JOAQCW COUNTY EWIR0N?.1E`lfA- <br /> t,LTH DIVISION as soon as It Is available and At the same Gott it ie provided to Inc or my itpratcnudve. <br /> PLEASE PRINT <br /> N?LICANT NAME * SICNAVURE <br /> .,I F DRIVER'S LICENSE a <br /> IIRFW <br /> fnuQ$(1LDW RFOI <br /> —.�._:. <br /> airov_ 'Da ,(�Rfce,Prvicesa add: 'Del__... ; <br />