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�. [ X05 Tlll ices IEnvironmflal Health Division <br /> REEN FORM <br /> DATE /0 //,7 /0 - MASTER FILE RECORD INFORMATION "MFR" <br /> x UNIT IV <br /> siA19€1€sF HH Ji Eo 4 '- EIF <br /> OWNER FILE <br /> COMFLETE THEFOLLOW/NG PROPERTY OWN/EAv�/R INFORM'A/%TIION: /n/ F/Fv5 CHECKIF OWNER CURRENTLYON FILE wire EHD <br /> PROPERTY `n� U1,10 / C t •c�G� `-'' ''v PHONE L <br /> Jrl V1V �(6 �I gas -�6 �� <br /> OWNER NAME I, <br /> Ao / eKe <br /> �7r�/U///�llL,,,,���'�/ /�SS�. M f�V4. RSOC SEC/TA%ID# <br /> BUSINESS NAME <br /> Owner Home Address 17'7,5q Stl ^A �R11 .W DRIVES LICENSE# <br /> City S '�OC '�� — C14 / STATE ZIP <br /> Ownai Mallin,Add.... ( ^� <br /> Mailing Address City YI State Zip <br /> CORPORATION INDIVIDUAL❑ PARTNERSHIP❑ oU 'eWG FED AGENCY 11 OTHER <br /> FACILITY FILE <br /> COMPLETETHEFOLLOWING BUSINESS FACILITY 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 a NEW TYPE off regulated Business 7 YES H NO ❑ <br /> BUSINEsSIFACILITYISITE NAME ETC <br /> C 14 -L{/ L,(f <br /> SITE AoORESS _200 NC'[Uj/1` .A. /� �/ SUITE ^BUSINESS PHONE <br /> CITY LV Q� �IJ�L.r` ✓"C(.( N/ STATFJIAvTzip <br /> 3VlDj <br /> I�.. rt"S1„�` L.P.aiIL"OO�I,. I s ..�I Sgla CG <br /> �u I ..a.. , s. �.. �. er I'. nI . <br /> Mailing Address If DIFFERENT from Facility Address Attention: or Care Of(optional) <br /> Mailing Address City 3yy p + STATE ZIP <br /> Affl,✓ f ,—*fty S`tu� <br /> �'i�StiiSlskt �f1�`�n ixr'fsz��"P^ �� "A <br /> THIRD PARTY BILLING INFO: Complete if Billing Party is different from Property Owner orFacility Operator idenbYted above. <br /> BUSINESS NAME Attention:or Care Of (optional) <br /> Melling Address PHONE <br /> CITY STATE ZIP <br /> ACCOUNTAODRESS for fees and charges OWNER FACILITY/BUSINESS THIRD PARTY BILLING <br /> IIILI,ING AND COMPLIANCE ACKNOWLEUGNIENT: 1,the undersigned Applicant,certify(hat 1 not the Owner,Operator,or Authorized Agent or this nosiness,and I acknowledge[hat all <br /> PFRAUT FEES,PENALTIFT,ENFORCFJtFNT CMARGEr and/or ROURLY C/IARGFf 11550Clnted with this operation n'lll be billed to me R(the address identified above ns the ACCOUNTA1)URF_S5 <br /> for this Site. I also CeAiry that all Information provided on(his application is true and Correct:and that all regulated Activities"ill be performed in nccordAnce with all applicable SAN <br /> .IOADIIIN COCINI Ordinance Cod"And/Ur Standards and SrATE nd/or FEDERAI.LA\V5 And Reglllalions. As Ih[undfr5ignfJ owOf4 aptlP+nc..nY a[tJlt el the nnu,rrl•_IacAlfll AI Ihf <br /> above rafllity/site address, I IIU[by Rllthurize the release of any and All results and environmental assessment Information to SAN J rIWNi AI' <br /> HEALTH DIVISION as soon a5 it is available and At the same time It I5 provdd to me or my repr"enlalive. <br /> I PLEASE PRINT / / <br /> X APPLICANT NAME QII R S4r© h G��/E Z,),fe 4r,, SIGNATURE <br /> M qA 1h C't tr PHDRIVER'S LICENSE <br /> N 611 <br /> TITLE ' l Nvl ( OTOCOPY RfOIIIRFnl _ <br /> d'j �`�ji ` c 3 '`� I dc`ooifnNng [late <br />