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:9e{no�qu"inYFC2yi ` lealtli S rvices� Envnonmrjh' •iealth Division <br /> ... . FORM <br /> DATE MASTER FILE RECORD INFORMATION t`MFRIr GR EN <br /> >✓ f O1o3s7oo <br /> $Mases aarwarOa EHD VMONL+ E O UNIT IV <br /> le T <br /> OWNER FIL[.*1$ w , <br /> COMPLETE 77-IEFrOgLLOW/NG PROPERTY OWNER /NFORAIIUON: CM6grry OWNER GuAnewrtrou cuF tr,Tw EHO <br /> PROPERTY / �QD ��Si�L� /Y 1NONE <br /> OWNERNAME GG y ',R2agJ333-11, <br /> � nv M; arc <br /> BNSINE6E NAME J'OaO C G r✓S T"R veli 0 el ci:j f')PAbVy sot sect TAX IDR <br /> i <br /> Owner Home Address DRIVER'S LICeNse t <br /> city STATE 21P <br /> Ow,yr MWirp MdraeP / 34 ,�' t-0r KF-ifdQQ S` r <br /> Mai .1-� <br /> ling Address City L-O[))I stater,R- UqIg <br /> p l -fO <br /> C.ORPORAT INDIVIOVAL PARTNERSHIP Fry AoeNcr DTNEp <br /> M <br /> FACILITY FILE <br /> .E,)s—, o 1. .r._:.,,....y;, ,�.,,.np11 t�err YAY- r ,17w;..w•;"twy";C:{?A. IS _. <br /> � .. A .-•t Ab CR0491REF 1��5 -...�,�Unr:;a-- .. -..ACEOIINt',f..Lep .�..I.��p �r�-T-� . <br /> COMPLETE MEFOLLOW/NG BUSINESS/FACILITY I SITE INFORMATION.' <br /> Is this a NEW Businesa LOCATION not previously regulated oy the ENVIRONMENTAL HEALTH OIVIWON 7 VES No <br /> Is live an EnarrmO Business LOCATION but s NM TYPE of regulated Business? YF ❑ NO ❑ <br /> B'J&NEBa/FAgLITYJu1TE NAME TO 2-'> CCfJSI'A VC.T-/Or./ 19'q IVY <br /> SITE ADORESS I g if, <br /> 1 '4VV%1 J2D SUI?204 B3:TjPHONE <br /> cm, L-0 STATE C,q <br /> I!� <br /> ZIP <br /> BoARadETStFo'atvisoR :: L ,r.7,77 <br /> Mailing Add-ass lf0/FFER_ from facif/tyAddress Attention_or Care Of footionao <br /> 63 �vcKci-oRJ S �t3�aT Jd.� S <br /> Mailing Address City LV a 1 STATEC/4' ZIP Lfo <br /> SIC.CopE APN'N —O• Q "' j COMMENT:.O L.ID 'yi Gib <br /> THERE,PARTY BILLING INFO: COmpfete if Billing Party is different from Property Owner or Facility Operator idendfiedabove. <br /> BpeINESE NAME 6RDv,�D ZE<0 A,-/,o L-y SLS) (,J C, Attention:or Care Of (optional` <br /> Mailing Address l�1�7 /L-F r II 5 I r PHONE 2oq S38` —q 8"$$ <br /> cm �In.cA}L.O"� STATE ZIP q�" 320 <br /> ,� CJNNsgPygEss. for fees and charges OWNER FACIL17Y/BUSINESS THIRD PARTY BILLIN <br /> BILLING IND COa1PLiANCE AaaowLEUCMtNT: L the undenigaed Applitnat,certify that I.the On•ser.Operator,or AuMorf rd Ayer!of this shire ss.and I Acknowledge that an <br /> PSAurrFrxs,Puv,Irn[.c 6NvoRCenmtt'CIrnRGGT aadior Nnvu:YCNUY.'ce assnebted with thta operation will be billed to meat the Address Identified Abave as the AY,LYrL•.tTADD -S <br /> far thissite I also¢reify the as Infermatior provided on this appkntion It trot and a rreI and Alae all re¢ulate l aedvities will be performed in necommun with all goplieabw SAN <br /> JOAQLIm COUNTY Ordim mCadafodrnr.AzDdanU cued STATE AAWQt MEDEEAL lrws and Rcgumt ons. As the undersigned owner.Operator.or intent or We property Mes,Md at Me <br /> one"f"t3her address.I hereby aatborim the releme or any and ae More; and eavi unmental uaussnumt information .lN IO.LQL.IN C liNJI ENU7RONME\TAI. <br /> HEALTH DIVISION m soon as It Is avah bit Aad at the same time it N provided to me or my repraunmtiay. <br /> PLewae PmNr <br /> APPLICANT NAME (9ky4L+'C' ZFLto ANN[..YSIS SIGNATURE/ �. <br /> TITLE 6'GLEGcrL+� P- ST)qfs/J CCL �2 DRIVER'S LICENSE a A <br /> Ir <br /> . -rJ� :,Td"i ,r--?+�u, Auobura;itraDit�ar"R`ieasliitl - dey%' - Date �'- .� - <br /> 3-'trizp l <br />