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•FORY•[EHa016{REvlaeo 101311Y81 <br /> DATE (--NMASTERFILE RECORD INFOR NTI <br /> -ft==1oniS FOR EHQ U Avt r Awrriw=a lir . <> Aa k ' <br /> riM OWNER FILE <br /> CIiOMPLETETHE'FOLLOWINGBUSINESS OWNER INFORMATION. cx OWNER cuxxevnroN�uew�r►rLNo <br /> F•: NAME <br /> . -------Fr=y- r2�?) 4 S i Ll I Ll`i € <br /> .............................................._........................_............. .... <br /> fitmwss NAME(If dUl'snrnf ftin Owner Namal Sac ow 1 T"to/ <br /> Rt U N 1•4N911126 IM 1/ AA ��S 0fQ7 <br /> Esa RUCK LEY C004— W A <br /> Glty .7/ 17W -r0/L/ erwre� Zlr S <br /> T <br /> OWNER MARLING A ME48 1/O1FFF.RENT*nm OwnerAddrws Atlentian:arCare of (optlonalJ <br /> Mailing Address City 5-ro 14I �.,J J stats zip S "06.� <br /> TYPE OFOWNEROMP: �M[l - . <br /> CORPORATION Lig JNO1VIOUAL❑ PARTNERSHIP 17 LOCAL AGENCY❑ CouNTY AGENCY❑ STATE AGENCY❑ Fen AGENCY❑ OTHER <br /> FACILITY FILE <br /> 'M'.: s. 'tq' - - s:° iwca4iiNT tl1 <br /> COMPLETE THE.FOLLOWING BUSINESS FACILITY INFORMATION: <br /> Is this a New Business LOCATION or VEHN:Le not previously regulated by the ENYIRONYEKFAL HEALTtN OtvistoN? Yes EI No <br /> 1 this an emwnNo Business LOCATION but a New TYPE of regulated Buainesa? Yes No ❑ <br /> l3uww&a1FAcam NAMe(Tram wILL ee THE NAME ON HEALTH 1'E[tMIT) . <br /> v ' I�OI 7 AJAi - 7 <br /> FActuTrAnimess(1FFACAJYY AAtoo"FixwLhrrawFowVaoctcCLAmComlgnayA mfi) SulEt 9uelNessProNa= <br /> CITY 1FFAcw►yrsAll/oa"F000L"TomF000VF.omzznE W Q <br /> 574CGr-�G Aj sTCL1 '7 J Z 19 <br /> :: .i: _ - <br /> gQApoiiiiSis�/nnsoir-DlnTreicY;' <br /> Mslling Address 1br1faJ111 Par•mft 110jFFERF.W*0 M FsaNRyAddress Attention:or Care Of(opdarml) <br /> X G�70 <br /> Mailing Address City ,.. O��Q <br /> (2.1 Z�62,0f <br /> 21 <br /> Tl11Ra PARTY IBILLIPIG INFORMATION: Complete If Billing Party Is dlfferentfrom Business Owner Identlr7edabove. <br /> _..... .............._ .......__.............._........... ......... . .... ..................... <br /> aUMNEss NAME .Attantion:arCme Of (opflomi) <br /> Malting Address PrtONE <br /> i <br /> CITY <br /> .. T STATE ZW <br /> iagRUNT-AQQRE99 for foss and charges OWNER ❑ FACILITYffluswess ❑ Tmzn PARTY B1LL[NG ❑ <br /> BILLING AND COMPLIANCE ACKNOWLBDr.MENT: I, the undersigned Applicant,certify that I am the Owner, Operator,or Authorized <br /> Agent of this Business, and I acknowledge that all PERUIT FEEs, PENALrms, ENFORCEMENT CI!'ARGES anal/Or HOURLY CHARGES <br /> associated with this operation will be billed to me at the address identified above a$the ACCOUNTAADRESS for this site. I also certify <br /> that all information provided on this application is true and correct; and that all regulated activities will he performed in <br /> accordance with all applicable SAN JOAQUIN CouNTY Ordinance Codes anti/or Standards and S'rATR and/or Fujmuwl. laws anti <br /> Regulations. <br /> i PLEAaE PRINT <br /> -. APPLICANT NAIAE ' ,L/O �j UIZA �6a)"r , 9IGNATtIRE�� _. <br /> TITLE , f may] /[ DRIVER'S L110EN�8fE7A <br /> A ,�/Q/�►/r]� �PNO70GAPYREOl1kFEnl 13-/ filo _ __ <br /> iA .Pra�etl,py Ileal �►ggaunUn 1a►flaTs Iae7oom'lnp Gompla!!3�!RY...,.�;..,:., , plwkr Il, <br /> 4.. - ..... - �.....:�> <br />