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APR 26 '04 16:28 FR INT RAW MAT*PORT T4 503 286 8716 TO 12099314606 P.03iO3 <br /> SAN JOAQUIN COUNTY UBIJC IiEALTM SERVICES ♦ EN-VIRONIrEN" 1EALTH DIVISION <br /> FORM (sit an IsiRevlses lolatsal <br /> DATE MASTERFILE RECORD INFORMA- Y ( ftfJ Tp/Z� <br /> OVIINER FILE <br /> COMPLETE)rNEFOLLOW/NG BUSINESS OWNER INFORMATION: N <br /> G" ,r OWNER CuwweNnrONOLfw rieEHO <br /> BusINES11 OwNrn I II i Pnowt I <br /> NAM! <br /> --.._-......_.. __......– --•..._.,.__....__.._.........--........._.. <br /> . <br /> .... <br /> ................. <br /> _._-._......... ..,..._... I <br /> 1 111IMP4se Name of dvff r lIFem i.r 71 I sot Sec I TAA 10 A <br /> AA en `G B,4 t NRLS <br /> QiirrtAl�neEAOontaa / _ r` <br /> 1 • <br /> I ay i 9/wr zlr <br /> 95a1 Z- <br /> L i <br /> i 0V MER MAIUW Anni-"S MnIFFERENTAvnr Os wrAddreea ! Allunllan:arCare of (op[/wuq <br /> i <br /> MalMng Ardrees Clry �� f ZIP <br /> riot of Owwtgale►: <br /> CORFORATION❑ INGNIGUK 2t PARrMERSHIY❑ LOCK A ❑ COUNTY AGENCY U STATE AGENCY❑ FED AQENCY-I) OTHER 13 <br /> FACILITY FILE <br /> :::Y::: a- I iLiiTil <br /> COMPLETE THE.FOLLOWING BUSINESS FACILITY /NFORMATION: <br /> la this a NEw Business LoCATwrs or VEMICLE not previowly regulated by the ENviRowulimTK HEKTII DIvlSION 7 YES ❑ <br /> Is this An EXMMG Buelnsee LOCATION but a New TYPE of regulated Business 7 YC. D NO <br /> B a7Filos M pwC(7r» u sc■nt NAre oM HEALTH PER- T) <br /> I <br /> �� "�s <br /> 1 T I <br /> FA AaosEsa(sF.r rYI.YAARON LwrarF e ( surn;t ; aw"EllPlawt i <br /> t7rr s�FACl11YNAAIbeNf fOGdIAMILNF•OeQO VkreGat uotly�i>1�rAnnitrss Gln/ w <br /> zip <br /> i , <br /> r <br /> ',R�::: .. ::WA:+ ..,'A.'f:{'�::':. •:( � -dei::::: i ...........�... ,i.•...i,.'..�. <br /> 9gA.R ....7ilM�.lid1lp11rMIG1';; a.t�!►T .... .KIM'''::... ;KM�''�ie:: <br /> Hellin Addrses lbrl/ i/lA Psrml/ MO/FFCREM/Mm FaolMd Address AILnUan:or Cars Of(bollf-20 ! <br /> �0 ssCt <br /> Ma1Wp AMrses Clly J�C /K ) i iTwlf ; 2w 9 _/,Z <br /> N 7 <br /> 00, <br /> _. p/ .lag Partx /s dflferen_t f/'om Business Owner /den//led aUove. <br /> THIRD PARTY BILLING INFORMATION: Complete)f Gill..•.........., y_.............._. ....... .....__.....__..._...._,...-.,.................,........, <br /> BusumasNAME -1l 1 .Ali—U.n:orC.re f (opd—ey <br /> r tl7Rd 4 Iri Mir <br /> Mailing Address4� PI O ' <br /> k[04 0 <br /> I ' <br /> try <br /> gjkGj r,4Qflfffjg for foes and chargee OWNER ❑ FACIUTY/BOSINEss ❑ THIRO PARTY BILUN <br /> HILI.ING AND COMPI.IANCh A!,-KN0WI.R0GMHNT' 1, the undersigned Applicant,certify Olaf fain the Otwier, Operator,or Authorized <br /> Agent of this Dusinesv, and I acknowledge that all Pettti✓Ir Fees, PEN uxms, EN('OI(CEhll7rT C/LINOES ;11111/Or HOURLY 01,40oL' <br /> associated with this Op6ratlon Will be trilled to tilt 8t tltc addre3s identified ithovt at IIIc ACCOUNTA/)IIHEss Air Ihis site. 1 also certify <br /> that all information provided on this apptic:tRon is tnle alld correrti anti Ihat all rcgislated aclivities will he perrormed in <br /> aCCOrIIaaCC With all applicable SAN JOAQ111M COUNTY QrdilrikRCC C•Gdtyr and/1)e 3111dards and CJ'1'A•r,, ndler FIJN!IIAI. LA1Mii wnd <br /> Regulations. <br /> P►t•se PRINT <br /> APPLICANT NAME Nyr�_ ✓l'1 CL �r�1� 81GNgTURE `> <br /> TITLE Oct)N e2 1,1.1 /,,! _ l pRIVER'a LICENBE/ Qa S 3 QZ Irl <br /> ruoT'OcOlr wEwAnEn •u ZS <br /> ,:•I ,•..�..n:�:;�:,:X::. .,:.,.t,..�s:la.. � R ..<.... a . . .: eau 11l.g. 1195 r14- <br /> ............ .. . ...... <br /> ................ . ......... <br /> APR 26 104 15 51 209 94p01F?T pAr:G 010 <br /> ** TOTAL PAGE.03 ** <br />