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St1 6J18�H 00-4 Evii ZMUT.96Vif, ..;;alx,He Ith,Di4isii�ri F, ,��:b lad <br /> DATE 10 //-7 /Q MASTER FILE RECORD..INFORMATION "MFR" GREEN FORM <br /> 51160.0 ARLSTom.EH4-mor—Q T —DwNBlflM*I MWI$N1 UNIT IV <br /> CJ4)ICO2 19(o OWNER FILE <br /> COMFLETETHEFOLLOWINGPROPERTY OWNER 1NFORM'Anotil., n 1M CNEcNIF OWNER CURRENrzroNFILE wrrNEHD <br /> PROPERTY rim 7/6k Vu ) /•„n., D + V eiAV�' PHONE <br /> OWNERNAME J eiLy7 IV 1..171 RIF —In ? <br /> no a N M, <br /> Busmess NAME l-� .1A � 6p40/E Vee <br /> -Al-C-�S., 14S 1. /t'7(ar�, SOC SEC I TAX to <br /> Owner Home Address - / �/S q Sn /�� ,w r�� // / DRIVER'S LICENSE N <br /> City S �OGlT {�� / •4L ( / STATE ZIP <br /> Owner Malting Addree. I• 1^v l�//"rr 11 <br /> YI <br /> Mailing Address City Startle Zip <br /> CORPORATION INDIVIDUAL❑ PARTNERSHIP 11 o,1 6416 FED AGENCY OTHER <br /> 4.OD ISzO-j FACILITY FILE <br /> i aiY1: s %ioE$ II�tF // "e. fw Ma +} , aT �t rifk#� Tame <br /> COMPLETETHEFOLLOWING BUSINESS I FACILITY If SITE INFORMATION: <br /> Is this a NEW Business LOCATION not Previously regulated by the ENVIRONMENTAL HEALTH DIVISION 7 YES ❑ NO <br /> Is this an EXISTING Business LOCATION but NEW TYPE of regulated Business 7YEsX1, No p <br /> BUSINESSIFACILIWISITe NAME �(T/t •t �C�j/ <br /> SITE ADDRESS Or;JOQ•J'✓A/C/lvl`O'rC);ttaM/ SUITEN BUSINESS PHONE <br /> I 6P69 Jre s�3� <br /> CITY LO Q� STATV/4 ZIP <br /> ... r� � .• CLL <br /> f {' <br /> �"I�KC=rte.:'jd=`P,��'e,�, <br /> Mailing Address IfDIFFERENTfrom FoollityAddress u Atlenllon: or Care Of(optional) <br /> Mailing Address City STATE ZIP <br /> THIRD PARTY BILLING INFO: Completeif Billing Party is different from Property Owner OrFacility Operator identifiedabove. <br /> BUSINESS NAME Attention: orCare Of (optional) <br /> Malling Address PHONE <br /> CITY STATE ZIP <br /> asyyUNTAODRESS for fees and Charges OWNER FACILITYIBUSIN SS THIRD PARTY BILLING <br /> ILLINC AND COMPLIANCE ACKNOWLEDGMENT: I,the undersigned Artl4kenl,Oerllfy HiAt I Am Ilia Owner.Operalor,or Awhoriied Agent of ibis Rnsiness,and I Acknowledge flint All <br /> SRAf?FEES,PENXLTIFT,ENFORCE11F-NTCRARGET And/or R0URI.PC11ARGF_T AssOdated with this Operation Will be billed to me at the address Identified above as Ilse ACC'OUNTAUIIRFw <br /> r(his site. I aISO certify that all Inromlallon provided On this application is(me and correct;and that All regulated ae Hvill"DTII be rerforined In accordance Will,All Applicable SAN <br /> IAGUIN COUNTY Ordinance Codes And/Or Standards and STATE AOd/Or FEDERAL LAWS and Regulations. AS(lie,mderalanad owner,operator.Or agent Of lite property located al file <br /> 1ol'e 1kcililyishe Address, 1 hereby authorize Iia release Or Any mild all results And enviranmenlal assessment Information to SAN JfLMIBNTn11NnT MWHATiNAIFIVI AL <br /> EALTH DIVISION as anon as it Is available and At the sonic(line it is provid to me or my reprrsenlAlive. <br /> L <br /> PLEASE PRINT / <br /> APPLICANTNAME %�) O� N R S"t LQ ►1 A9.06' UCC//,fj) SIGNATURE ./yam'_'" <br /> TITLE �Vl f' a _ - DRIVERS LICENSEN <br /> A, ,�.,RlT +� �ir�,�p /vHnrnrnar RFrnl aEnl �' Lst p <br /> Y• �Sla« s, c ate Tfi'AW"s 'r.,"�drDz':N' +'z. •T ���dOnliil`id fl'b2 bFill ee`elri omple�er)B...y.L,c.1 ere , <br />