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� OAS 3 97 -'••� -ouNT>r , puBi.ic HEALTH SERVICE, ` it <br /> SE�ausFOR pU r MAs7ERF,lLE RECp EIVVIRONA#ENTA' H�tTH DIVsrr <br /> btlrNEtt RD INFOR �riN <br /> eusll�ss R s <br /> IIYIVER <br /> FILc,...E AS <br /> E <br /> s <br /> 1&............... OC......................ETHEFOOW/yG BUS1NE55.�WNER r <br /> / FO <br /> "ON.' <br /> ......._ <br /> NAME ...... <br /> -# + cK,F OWNER V# <br /> ........... -.... . uRRFNLYON O 3 41,11 <br /> H/ E.... 77D <br /> f <br /> 8uNun:ss NAIVE(if di I+enEfrom.._.. ..„..._ .. ..._.�hrl` -- _ _ _. FNc)W .. .. <br /> S S 0. Owner Name) _..... .. .......� .�1lsc.:..... '}�. .�... ... �Q q �!7 <br /> 76 <br /> l OWNER Hc)vE A0wESs � If : Soc SEC/TAX 11)Chy <br /> # v } <br /> ORR/ER'N LXEMSE0 <br /> �i <br /> OwWERMAIUNoAooRENS /fOIFFEREVrfi+omOwnerAdd ki SrwIF ` Zrp <br /> 0 2 .� ' <br /> Q Ill k� Attentlu,l:orCpare of(opliarla/J <br /> XWingAddress City <br /> Tt7rVI <br /> Sta <br /> TYPE OFOYINERglpp: IjSz O. <br /> CORPOPATION17311 1N01VIDUAL❑ PARTNERSHIP❑ LOCAL AGENCY❑ COUNTY AGENCY D $TATEA22=❑ FED A%0{ 0- OnIER❑ <br /> FACILITY FILE 11 <br /> i <br /> "'FACILITY. 5.....:,::. ... :: GROSs1iEF:II] ....... ;:...Accaerir�s roi / <br /> COMPLETE THEFOLLOWING BUSINESS FACILITY INFORMATION: <br /> Is this a NEW Business LOCATION or VEHICLE not previously regulated by the ErmRONNENFAL HEALTH OiY'y ISION? YEs No <br /> Is this an EIasTING Business LoCATION but a NEW TYPE of regulated Business? f Yrs IT NO <br /> 8LwNEss1FAceurY NAME(Tmsvnu_eETHE NAIrE oN HEALTH PERMIT) I <br /> S0. r Ou � CO ...0 U-1CC it <br /> FActmYAo4o'AE`ss(IF`FAc1ru'T'rISAlflto &EFoo�o�UAoroRFawVeamEuseCowessARrAooREss1 ;' Sul E1LwNEssPmowE <br /> 2-0 5741-7 <br /> 7�/Q_ i <br /> Cn T IF FACK rtV IS A M ia&E F000 UM r oR Room/9 use,CowsaamwAnoREssCiTYI STATE ZIP— <br /> +-CA) �� � Cly ¢5-2_0 . <br /> BZuue>ZaR9ia+tvlsora]IssRec> ;' .... ateY1.. . <br /> „aK .. ...... ....:: <br /> ... .......;::....... .. .. .......... :....................... .: t <br /> Mailing Address fol Plermlt 1FDffFEfiE vrfiwn FA=71 yAddrass Adention:ar Care Of(opeb-I r <br /> MaAddress City STATE ZtP <br /> iling <br /> i <br /> SIG CaaE APK#. . ...... ...... t;oesElrr ......: ......i.: k <br /> THIRD PARTY BILLING INFORMATION: Complete if Billing Party is ditfererrtfromBusiness_Owner Iden above. <br /> es ss NAME..................................... Athantion:arCara Of(ap8lonaQ <br /> (n uO..rGtN lkd&rnj <br /> �li dress PHONE <br /> ,�fL4 r 3&0[y O <br /> [D�S� QOIJ�`�10.5 1TllQlyll�2 f' <br /> sYATEZW <br /> rJS2Z� <br /> Cr” <br /> ACO2 EADDRFca for fees and charges OWNER ❑ FACILITYffiusi ESS ❑ i� THIRD PARTY BILLING <br /> BILLING AND COMPLIANCE ACKNOWLEDGMENT: I,the undersigned Applicant,certify thatk I am the Owner, Operator,or Authorized <br /> Agent of this Business, and I acknowledge that all PERMIT FEES, PENALTIES, ENFORCEMENT CHARGES and/or HOURLY CHARGES <br /> associated with this operation will be billed tome at the address identified above as theACCOUNTADDRE4S for this site. I also certify k <br /> that all information provided on this application is true and correct; and that all regulated activities will be performed in <br /> accordance with all applicable SAN JOAQUIN COUNTY Ordinance Codes and/or Standards and TE d/o FED Laws and <br /> Regulations. '' o <br /> PLEMW PRIMr <br /> APPLICANT NAMESIGNATURE ` <br /> lb okw i 1) <br /> TSE [� �„,/,Q_ 1, DRIVER'S LICENSE# <br /> IJ1 dal f}�a �y5+ `6LAa I 1 �a g-e uWal�(P}10TddorYREMMEO <br /> Approval 8y tlafe AcwuatlnQ:Ofrtaa fyrcesasing Dompieltad By ) m �� {rrr�.I: <br /> w6l 401 <br />