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Sates Joaquin County Enviranmentaa Health DePErergrer t <br /> GATE GREEN FORM <br /> MASTER FILE RECORD INFORMATION °`MFR" UNIT <br /> �w! T ,( <br /> e pw.o OirtleR p7s. OAeee UNI IY <br /> OWNI.R FlLtS � <br /> ...�f C aAf IF OWNER Cedit1=VoAIKWWaIEHD <br /> COMPLETEJNEPo110W/ PROPERTY OWNER/NPURNA770V �7 <br /> PRwrmyIJMTLLANANe /'M.4 eI PWNE <br /> Fdd I Mt lost <br /> BWIXfae NAue �ry�(rq/� 6oaeEoFTax IDM � <br /> Oxror to Addteas 2/714 / �, DPoYaya tJrtaaEa - <br /> STATE zw <br /> city <br /> tyam.rN.dmsAdm.oa f`G,y ,` <br /> YddWtaAudnu Ctgr ' eieta Zlp <br /> ywvmlWN❑ Itmmauu PARi1QIWUP❑ FOAeemr❑ owu El <br /> PAMW Pitt <br /> .PAptuiYlD• -0RaeRv IDI AowuNrlOs htv6 <br /> _._ <br /> CO pwm TNEFOLL01"No BUSINESS I FACILITY I BITE INPoRM4770AF.• <br /> to this a NEW Beelnew LOCATION notprevfoueyt rami W hY the ENVDtONYEN ALNEM TH DEPT.? Yes ❑ No g <br /> Is this an Emrsaa Business LOCATION Dula NEW TYPE of regulated Buslnesa9 YE% ❑ NOXI <br /> 6wltterdPAolurclBneNAaa N G .r G l M Jt� <br /> B-AaQaeee Z 3 0 a f,j, -S-r L_4&j EY , EuneE BueIN�.PxaNe <br /> OFv r�L Z„p eidre64 ZTP 9e to ,' - <br /> ISGtWiQPBUPfJiVItAx DIa1WOf LOQAl10N Dpw NEMS Nrl2 <br /> Wmq Attdms BCdNTMaa Fard40'Aaffiws Allndbn:er Caere Of(4ffmw0 <br /> Nsmtro Addnn Old 6TATE ZIP <br /> a�cooa Aoki Ca�T;r, -. . <br /> THIRD PART,BILLINa lwol Complete ifellling Party is dWerent from Property Owner orFaclllgF Operator IdentiNed above. <br /> BuetuadNAta Atbenti :arOarn Of(rptbadJ <br /> llelaro6 Addtrar PNoxe <br /> C111 STATE LP j <br /> eC,Nraxrl�nrsRn rorrede eRd ehef®tt QWNER FAciu-15UsNEss THw0 PA-,TY Baen:e <br /> en taw Axe Caanuaxa AndvneTetx:Narm 1,the andardyned Appaaet,cerab amtl Pm the Oexn,Opevmr,ar AafiarludAgmr of lhle Brdnm,and l arJmowhdpe Natell PamarF2u, <br /> Pautnla,BMD�RMQau¢imd/araooRrQwmrs uweWud wlN thio opemtbn w0 b6aed mematlheaddtm idevtllled oboreuthe Atrnen'rAoartav Wr tb4dte ldeo rely thot � <br /> A wrmmadoo pmvbled m thio eypEotion L true ud rorrott and the eC reyulaml antvltlre wW be performed In ecrardonro CAIN as apPmbie SAN JoAQNN COo Odie..Cede uWor <br /> Btmdmde and STARArd7or F'motAt.I..and Ravddora.As the mdenl�ed awee.eperomq or e¢ent of the property bandrt the Above fualth adreA,l hereby nnWortre therdeaod <br /> any nod as rode and tmira tel menmeet IvlormAdoo a SAN JOAQUIN COUNTY ENMONMENTAT.HEALTH DEPART u It N avaBAIr end at the vme oma It b <br /> .yrovided to me or ray tap— �yAn <br /> APFUCANTNABE �i- '4 F,/ eP"`NT 611INATURE <br /> TmE Ol✓�> ORNER'6UOEN6Es <br /> bXbMapMREaNREr) <br /> F2=i; <br /> oscwi Nord Gtr <br /> MASTER FaX RECORD GREEN <br /> 0 <br />