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0o ui County_aFoic Healtfi'Services iiEnvlronment eailth Division <br /> GREEN FORM <br /> DATE MASTER FILE RECORD INFORMA-I ON �*FRdr (� A I n <br /> t V `� lnl <br /> T IV <br /> 21. <br /> OWNER FILE <br /> peeaffF OWNER txarteFfrtr aY Ftl[wnrf EH0 <br /> yvIETETHE FOLLOWING PROPERTY OWNER INf-0RMATION. <br /> PHONE <br /> oim#r r OVmDt <br /> NAac <br /> Fug MI last <br /> Soc SEc/TU ID# <br /> Sat65 NAaeE c�e�aa� �2,a,,.z_�S �(Y\ tAn <br /> mer Home Address L'lo J4D� DR R'S lao=_Nsr# <br /> CloyZ S <br /> " 11D�S SIA,E Tx uR 1�D 1 <br /> oval.wu:ep AddecS <br /> Ie C1-e.lcia.. P...d tea, ta. <br /> sung Address C4 c Q V S C"-) 'CL.a+rmr sate Lo 4S$'� <br /> rrc nvmsv«ro <br /> m x - rbncc occ me <br /> rn <br /> N' <br /> Vvs a NEw Business LUCATION not previously regulated by the EN ONMENFA HEAETH DrvrsToti? YES ❑ No � <br /> thls an En G Business LUCATION but a NEw Tro of regulated Business? YES ❑ No ❑ <br /> eIDass/!` s /SDE NAME '` <br /> 0-iEVP0N S,-P-\3\re- S\f\tix Zbo 1� <br /> Su TE# BusutM PHONE <br /> >EapoaEss �7y I N. V.1E.ST �.•(,. <br /> STATE Z- gSZ�L lII <br /> h OF StdretY>soq DrS;RILT .•.� Lo&nom CAoF;.-I `:.� 'Rr:Y2 '(�: ,� RE12 �. u <br /> a0UV Address ifDIFFFAENFhom Fald&YAddn°xs Attention:of Care Of(optional() <br /> Co (-MD 10\\� p aft �r JIW� %2Z cmc . y� <br /> WWI Addles City SAn\ sYAre g4S.8� <br /> IC CODE sE <br /> 01RD PARTY BILLING INFO: Complete/P Billing Party is different from Property Owner orFaclity Operator idendffed above. <br /> u>�965 NAFtE Attention:or Care Of (opdonai) <br /> PHONE <br /> WWI Address <br /> STATE IID <br /> m <br /> t^"'•MT An^eF« for fees and charges OWNER FACIIIiY/6USINESS THIRD PARTY BILLING <br /> lP ' ' \ rmar� eedurlud A enl of Wh Bmiens,and 1 ackeo ledge that all Pt fr FE , <br /> ( e AMNOW1 car:Mr d.andmi oed'.'p�•I�. f r or A 6 <br /> uanq F.vFvatfxeNTOUItGEs aodfor Haucr6uarFs aasorla/eA Mth 0h 860 hie a addreu Weodfwd above ac da Arrnlmm AnnAvcc for this sites 1 aho certify llu t all <br /> taadna provided on thh application Is true and correct;sed dun all reyWated a tjAdea will be perforened to aceordaoee,Mdt all applicable SAN JOAQUIN CoemrY Ordloaoce Cade'and/or <br /> 'dards Ad STATE aa&cc F EvEaAt.Law'end Rc9%"doa E At the odeealyoed owxr,operator.ar RCI of the pmW rty located at the above facittyl ite addresa,1 bereby authorize tla release of <br /> gad Y eeadh cosi eovhunmeoW aswameal lo(ornutloa to SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DIVISION as so It b avallabk and al tiK erne lime h h pravlded lo <br /> ar my represeaaadw. <br /> PLEASE PIBRITf� <br /> PPIICAKT NAME Q'A� SI`J(� _. M, SIGNATURE <br /> D <br /> 1 ,��17-- ORIYERS LICENSE# <br /> I11E _. �'\Y,�. �C.��V\�10� (R1mOCVI <br /> 0W&eu.sir3:iZ.. Date f:3+sj�, tL '.tE, %1owu1itllq.Offioe PlnQessltl conwlebaa.6r. -- ":a -.e.5;riace•cSYr:;t:"st ':..s <br /> qw <br />