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k <br /> 'k�e� .�-a»io-c2"�'!6''-` 5 „�� fi:."�t•> r +.??R::-•c!-5 <br /> S.-: A <br /> &-''•- at:.�•x`v �Y����wsai�����.�r.-..�nvr,�>.'.+ � ..',e�ia� �'c yv�i <br /> .-;h::•i'I•'r vr. ..;. r y� � . rw.s,,....r .. r, >,Y�iir: <br /> FORM (MQ01S(REVM4E00 r11te - <br /> DATE ? MASTER FILE RECQR!] INFORMATION <br /> UNIT IV= <br /> OWNER i=tLE, A, <br /> , <br /> COMPLETE THE FOLLOWING BUSINESS OWNER INFOKMATlON: CHWECxff OWNER CURrra=yrt rompliF PW7WEHO <br /> BUSINESS .. ..z. ..._ ...... .�.� .._ PMONe ? ? N37 <br /> owNERNAME -----------------__:_.:.tin. �. _ -- ---F- - 1 ; <br /> BualNEss NAME(tf dflligravrt owner Name) We SECI TAX IA r 12.1 K.70 <br /> I.SrIFlt— IN � �Orv1G9�cf'°Off' /�iy+�tc.� - <br /> L' OWNER flosses ADDRESS F Damm 9 t.ICE WE P <br /> C" zw <br /> OWNER MAILING ADDRESS (IfOIFFERENThwra GwraerA ftwss) AlEention:arCare of (opEiarral) <br /> '7100 nS. .se- a, <br /> S?s go 0 d <br /> Mailing Address City a �� 64 <br /> CORPORATION INDIVIDUAL❑ PAR MERSNlP❑ LOCALAGOI r❑ O;UNW A6FNCY O SYATEAOEHtr C I FGrC avr:Ncv O OTFIER❑ <br /> FACILITY FILES <br /> COMPLETETHEFOLLOW/NG BUSINESS 1 FACILITY 1 SITE 1NFbRM4r►0N, <br /> to this a NEW Business LOCATON notP"WICUely bythe ErmRotrtttwTAL HMT"DIV1Swm 4 . Yrs ❑ . _ NO U-' <br /> i9 this an EJusnme Bugistess LO"="but a NEW 7WE ar nMUh t4d Business 7 Yf5 0 No tLY <br /> SUSINESSIFACIIJ•IYISiTE NAME. #; <br /> _ &HAM ►, � ) _ <br /> sIrEADDREg9 .Ian �? L I N N E - s�TE W <br /> STA aP' <br /> CJ? 5`3 76 <br /> r-.Y.;> :. - oot ;;:}SG.v. ^ :2..:. .R�:ocf' --..•� :.,AM1,.:-;x. <br /> d:wc NINE' n - i•r„%.;-n, aZ::?', ?'�3-oA. . <br /> mum <br /> i <br /> iAWKngAddress rYD/FFERENT8'rrrnF80WAda'r'saA ar(".areof(opw*430 <br /> Om3�jo ST FE 14 0) IArs �S' <br /> Mailing Address City _ srwTl? _ �P, 93 72c3 <br /> �;� •>:r.-3:�:xr...r....:o.•r:Y.t'.L'::i:'�`'c=i'�;9^ '” �v .L__-r � ti6f :}h. a "A� <br /> Y.t!Y-%�14�a6 i:..:,.:.�:.a�.:.Wt -.xt .. .. -- .: .r. '..A. _ - :..- __ y <br /> MOM <br /> THIRD PARTY BILLING INFORrATION: COMPIO s if Billing Party I$d#&went ftm Business Owner lderi ifredabove. <br /> BuslNEsa NwMe' A!lSmOor:arpye Of(opd mg . <br /> Hsiang Add <br /> rem 710 <br /> STATE <br /> for fees and charges OWNIM si FACa MBUSiNESS THM PAR7113ILlJNC3 <br /> RMLING A"CODSMANCE A['rtIvow&DGMV4 b the=mdasigaed Applieim4 c Mfy dwt I am the Oweer,Op--wr.erAmwkw;edA emw oCtbis Business,and I achaiawledge tbar.ail . <br /> pERwr Fees. pw"L7ws, EwoAczmwYr Caut=and/or.Haar CIS(Wm atsodated with'tha operation wig be bilfed to ms at the addrasa identified.above as the dt! <br /> d for this site- I also certify that all infarmadora provided on this appiiestion is true and cosset; and that all mplated aewities wig be performed in wmrdaace with atl <br /> applicable SAN J0AQllIIaF Coumw Ordinance Codes and/or Standards sad Si►7C.and/or FEDER Vw Laws and Regulations As the tmdetsigDed owner,operator,or agent of the property <br /> located at the above facillWsite address, I hereby autbotim the release of any and all results and,amroamemal asmommut information';!to SAN JOAQUII'i COUNITY <br /> Ei VIRONMEYTAL HEALTH VM31414 as soon as it Is available and at the sme time it proiided to me or my repsesantaaira <br /> i PLEASE'PmNT <br /> APPLICANT NAMESIGNATURE; `I ` <br /> TITLE /�6T �l�r/Jp DRIVER'S LICENSE 2 <br /> "}cC'�l.`%= .;.T.�•�.rbfGr.. vY:� mss• .c''2` .` 5:> ^�- r.3[-'. �t <br /> ,4 'e-3'•" �- -,r <br /> y z <br /> Z 'd 6;: . �. W0�1� HVL:S:6 L66 L—8Z—L <br />