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5-•13-1998 7:48AM FROM P_ 4 <br /> r <br /> J 4 Y. _ mC y ANN- <br /> M <br /> FY G"REen <br /> ' 777 <br /> DATE 5 _ 9MASTER FILE RECORD INFORMATION "MFRrr E <br /> N FORM <br /> �y <br /> iNnoroAawbaUNIT IV <br /> OWNER FILE 6 <br /> COMPLETETHEFOLLOWINGPROPERTY OWNER INFORMATION: Ca,:psr(F OWNER CvnRENTLYONF/16LWTNEHD <br /> PnOPLRN PHONE ((�� LI/ <br /> OwmLn NAME -2 Q 3 3 <br /> fivN IN 00 <br /> BusalEse NAME C R-U PC DEV6L-15p mi tN 1 ��ZP6� -I'-I OI�J SOCSEC/TmID# <br /> Owner Home Addreas .Lagl w In 49,Ci4 L�/� DRIVER's LICENSE# <br /> city r ! / STATE CA zip <br /> Oweer MMena AddlPY SAWIE <br /> Mailing Address City -5 State Zip <br /> CORPORATION INDIVIDUAL❑ PARTNERSHIPU FED AGENCY❑ OTHER 11 <br /> (/f FACILITY FILE <br /> A �• , ,: rl;:;i r" O I ' y ti„':.: '� `_IIS• ' <br /> COMPLETETHEFOLLOWING BUSINESS I FACILITY I SITE ImFORA/A770N. <br /> Is this a NEWSusinasa LocATIDN not pravilNmly regulated by the ENMt NMENTAL HEALTH DIV1910N? YEs O No� <br /> Is this an Exlsman;Business LOCATION but a New TYPE of regulated Business 7 Yes ❑ NO <br /> BOSINESSIFACILITYIStTE NAMEs�7 R-O PYA •� 1�,Q1+SD�SIj�c ES'IsATES Uz,, to N-n A-t- ncEuc= - mtar ,-r <br /> SOEAwfums Y SUITE* BUSINESS PHONE <br /> City �7-c)C�I�t-- , STATS Z'iv <br /> (:IAC Afo? ir5sf�n(+c-D <br /> 'IANI 1 dawn'W, tsiaq a•-.� m ]I:alall a.r"spn mi 1 a,. vs, 7 +'.r(.;tr- <br /> ' F.l;k. (IIA "1' ', �. •.r��,r.��l.�u.�'�CI�Y'Yf`!•i` s. Fw .M1 =4 I ,J 1 w��::..�....,. } .. »...'...11 <br /> Mailing Address IfDIFFEf�RBYTfrom FiaftAtlaMass . ... Attention: tar Care Of/optional/ .�...•... <br /> �'l/ZUFE t/�V EL-6�✓U.�WI- L.87c-Y OcY2�c'T1.6(J 17 oU�i I�1y Q11c <br /> Malting Address City 22q I w . M 4rcei(4 1iti . J'I� U�St�.1 STA ZIP <br /> T�''f� <br /> n•.. <br /> St Oda ' . . , ;aM'as'A+M-WskMw"tR •a.�•a'smW.� , <br /> 1}�.011 ,o-Y ' `5 •w dsl-+-.. 1(v • v`/�. ' ;-' -.-•. �'.,�. <br /> THIRD PARTY BILLING INFO: Complete if Billing Party is diRerentfrom Property Owner ot-Facility,Operator identiftedabove. <br /> BUSINESS NAME M LL,-t� C Atlenti(m:aFGara or p <br /> T�TII��-'I 1 /� "Z�r FF <br /> Mailing Address <br /> 1 ItUI Wr+ 1T4E� PHONE 9+(”. ('� 3�_ 3�9� <br /> Glry STATE Ct4 ZIP <br /> AccoyuTAooaess for fees and Charges OWNER FACIUTylBUSINESS WRDII..PARTY BILLING <br /> bILLMG AND COMPLIANCE ACRNOWL MENT: 1,the undersigned Applicant.certify that I am the Owner,Operdtnr,or` f feed ApOM f this Rucinerx,And I acknowitdgc that all <br /> pERM?Fk'6$Fk'NAiY/Q4,FNF(1RCkMYJVYCNAaGF.Y aod/0r f/UUAIr CNM(:51'suwciated with this operation will be billed to me at the address Identified shave as,the A(.(�npNFAMIASRS <br /> for this slue. 1 aBo certify that all information provided an this application is true and corral,and that ad regulated activities will be performed in accordance with Ali Applicable SAN <br /> JOAty m Couti v Ordinance Codes and/or Standards and STATE and/or FADLIIAL Laws and Regulations, As the undersigned owner,operator,or ascot of the property located at the <br /> above facility/site address. I hereby authorize the release of any and all results and environmental assessment Information to SAN JOAQUIN COUNTY ENVIRONMENTAL <br /> HEALTH DIVISION as soon as it is available and at the same time it 6 provided W me or my representative. <br /> // PLEASE PRINT <br /> APPLICANT NAME !L,c I � �J--y�P� SIGNATURE <br /> TITLE SElt J 1,0L jOC I � C( SSC/�-I'J '7,7 DRIVER'S LICENSE <br /> g. *1Fm ui cou OFflc§;prticaad nu Adm ieTsa 'v T `'Gale <br />