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06-15-1999 01 :35PM FROM TO 15102333204 P.02 <br /> ............. <br /> ON FORM (EH(3015<11��D�I�T <br /> UNIT IV <br /> OWNER FILE uW" D/v--3(p 15 <br /> Co,vpLETErHEFoLLowmoBusiNcss OWNER 1NroRmATiojv., CfECXIF OWNER Cl4TRENnrOAFmL9MvrHEHD <br /> ..................... .......... <br /> 04, le4olJ PHONE <br /> OWNER NAME -------- <br /> ............................... <br /> 8USJNSSS NAME(if Ciare~tftMOWrM1f MOVINI) i SOC <br /> AtLA6LF <br /> OWNER HOME ADDRESS /Jo-rAvAILA Li <br /> LAITOINV <br /> City <br /> STATE i <br /> ZP <br /> AJIA. <br /> OWNER MAfUNQ ADDR03i (04VIFFERIENTftm OMm1Ad*o=j <br /> L AVA"don:t;rCwo.of Nodwoo <br /> i Mailing Address City <br /> /07 Vq 7121 N Par,Kcjqtj - -11, s"'ICA 111 <br /> CORPORATON5 INDIVIOurit-C3 PARTNERsmip C3 LoCALAGENcvO CouNTYAG04=0 STATEArENcT 13 FED AGENCY M OTHER 0 <br /> FACILITY FILE <br /> CompLErErwPoLLowma BUSINESS I FACUTY I SITE INFORMA770N.- <br /> is this a NEW Swinass LocAno"notpreviowlyreauftbod by the EWRONMF%TAL HEALTH DIVISION 7 Y12m 13 No <br /> Is this an EXSTING BIsshlesa LOCATION but a NEWTWIEvf rmuMded Business? YES M No dg. <br /> SUSINeSSIFACAUTYISrre NAmii <br /> son&, P6 * <br /> SI'MADDRESS Surmo ammmPHOW, <br /> 1011kvw Por Vwo.6 <br /> CITY STATE, a <br /> P 9S <br /> 11�a Z <br /> Mailing Addreas d'CIFFERENT15,om FaCififYAddVaSu Adentlon:or Care Of(optidr®q <br /> Mailing Addromm City <br /> STATE 7jp <br /> Complete PARTY BILLING INFORMATION. C0Olete if Billing Party is different from,Business Owner leentffld eabove. <br /> ...,............................................--.......—.................. <br /> BUSINESS NAME <br /> A <br /> Atb, (opamw <br /> wA )era ez&v( � roffe5+ <br /> eller <br /> Mailing Addnnss aPHONE <br /> d% <br /> CITY <br /> STATECP A 1 <br /> AQM&TM=W for fees and charges OWNER F=uTyffiumess <br /> L the mdersig"Od Appncan4 c-rtifY Cha[I a-the Ow nq,OPaaorar,or Agan of IN,j;.7— <br /> es, .d I tdowtedge that all <br /> F-ory. Pz?"Lzm. C�"d/w HOWELr CX�w—laud vnth thi- 99�ti" 611 be bRIW to me,u the address idamiNd ttbvne a.the'Acr.Ourrr, <br /> DD vg for this ute- E also certify that all'.infenautiM provided on this applicacion is Trite and cornreC �d thele U ngul2fod AU be performed in -Tord�.nth ail <br /> I`Pfic2ble S�JOAQU�COUX17Y Ondi-wmi Codes ADW*r St"dard,=W STIT9 ,d/or FEDZR�La"mal Rvlsd 1,'a,mder&igned�,op�,. r agent of the Property hl <br /> 1&d ag the a6n� f4cAiW*tu,addrmss, I ht�by 2,Kfionze The rvl�,of =y, 1m4 A mokamd mvirontntptral inlionmadon to SAN JOAI)M.:Coum <br /> PLEASE PRINT <br /> APPLICANT NAME SIGNATURE <br /> F i;rrp-&t -40 <br /> TITLE DRIVER'S UC <br />