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1999 1 1 :49AM FROM tiV 53°��� �� Spg3 a P. 2 <br /> ., <br /> trurne� I� 1. <br /> w� GREEN FO M <br /> W 0Z29 MASTER FILE RECORD INFORMATION "MFR" <br /> "°Ke UNIT IV <br /> OWNER FILE <br /> COelFFouowiNGPROPERTY OWNER /NFORMA77p/y GNIMMAP OWNER C�6NnVONRLENrWEHD � <br /> PROPI:rm C <br /> OwNERNAME (' //V(11411//VLCC PHONE <br /> � 209 53/- /s71 <br /> Fan 4/ yy <br /> BUSINESS NAME SOOSEC/TAx IDs <br /> Owner Home Addresm DRIvEN's LpcewsE k <br /> City r. 6 (3A1< / U ) <br /> (�/NbEn,' CAC,IFcVt F.JIR STATE�� ZIP �s `L 36 <br /> Owner IA N.I;Addr. <br /> Mailing Address City P4 46o�f State 21p <br /> CORPORATION O INDIVIDUALS- PARTNERSHIP D FED AGENCY❑ OTHER❑ <br /> D FACILITY FILE P R 50 37 <br /> a <br /> COMPLETEnsEFOtiOW/NG BUSINESS I FACILITY/SITE/ rollzmriow <br /> Is this a New Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DIVISION 9 YES Q Nl <br /> Is this an ExIsTIN°Business LocATwN but a NEw TYPE Of regulated Rusin"a Z yEs 0 NO <br /> BUs;Ess/FACIUTv/SITE NAME Nkw V 1 <br /> SITE ADDRESS t U hrtFiJ'rL1 V-0 e A N-r LOT" <br /> SUrtEa BUSINESS PHONE <br /> �, su VT 14 ST ('p 2NrrL Or THF StiTE25 t�CTt�r' or <br /> ,41?c i op✓� /�W 4' STATE 2tP <br /> LT'6UPROT�DFIDIJ � I, y� rL� , .'ML:OCN71�Cb06^'p :.. :f <br /> Mailing Address WDIFFEREAT 15,o n FaadwyAddrase Attantlon:or Care Of(aptional) <br /> URS6k)C /401(-/s /fi-)/cel,-.r <br /> Mailing Address CKy5 STATE(/� ZIP <br /> 1I �F1KMW4!'i� a r,lr ...., <br /> � /. .. <br /> THIRD PARTY BILLING INFO: Compete%(Billing Party is different from Property Owner al-Facility Operator idenlifiedabove_ <br /> BUSINESS NAMEA / ) r ABention:grGere Of lopf%onal) <br /> CSW H01-(- 'T �N1LL/P-.F <br /> Mailing Address �0D CAL/)-o✓Lti 1W S/. tom' ,5"Z) � PHONE y( -77'1- 27! <br /> CITY <br /> ACGQVArAODHES$ for fees and charges OWNER FACWTYIBUSINESS THIRD PARTY BILLING <br /> BILLING ANO COMTIJANCC ALTCV0% L W.MTNT: 1,[be undervplryl Applicant,certify that I am the Own".Operelor,or Aathorired Agent of tbis Bueift",Aid)a,kuowk*,that all <br /> PE1PHIr FE .R&vAz r ras.FNFOACZ?4 M01 AGET and/or Houaty C7l,a A4vNiated with Ih)a Operation will be billed to me at the address identified above as the AlY.nt AIMAESC <br /> for this site_ I alm cerdfy that all information prOvidod on this application u��true and correct;and that all regulated activities will be Per1lormod in accordame with W applicabl0 SAN <br /> JOAQULN COUNTY Ordinaeee Coil"and/or StandardT and STAw and/or e4l.EQ La"and Regulations. As the undeea lined owner,operator,or axedt of the property located at the <br /> above firdlity/site addron, I hereby satborfTc the ml a of any add aD resole and ravwnmcatal aascsMrrnt m1brTaation to SAN JOAQIBN CO(Wry ENVIRONMENTAL <br /> )IEALTH DIVISION AS SOON AS ilia available and at the same tune it is provided to me or my representative. ft <br /> rT �I�� <br /> PkEAsE PIaNT / {U�•y��lltV'I <br /> APPLICANT NAME 1�oLL/S / /LL//�1 SIGNATURE <br /> e <br /> TITLEGeb to 6 U 7- - 4,�e J'6 HI`. DRIVER'S LICEwsr st ,IA(PHOTOCOPY REQUIRMI <br /> S+�6y <br /> AZA ro M 1, .,.._.� ynrt»^-. r. ... •14 .,.,,.4 I tOilt6.�1 SIO <br /> _7471 <br />