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S-13-1998 7:48AM FROM H - u <br /> f <br /> GRE INFORM <br /> DATE J_ 19 _0) �3 MASTER FILE RECORD INFORMATION "MFR" <br /> gw,oco AvrAa rca END ua.Dw�T _ UNIT IV <br /> OWNER FILE <br /> COMPLETE THEFouowlNG PROPERTY OWNER INFORMATION-• CNECXIF OWNER CURRENTL YON FILE Mani END ❑ <br /> PROPERTY PHONE ��J 1 <br /> OWNER NAME <br /> FiW N pN 1 <br /> BuswEss NAME $oc SEC 1 TAx ID# <br /> Gi2u?= 17cvir�-aPM�r=i �;:F�Pel7�'<-�c�; <br /> Owner Home Address 22-91 iAi DRIVER's LICENSE# r� <br /> ty $TA ^ %k] <br /> (,`� �. � TE `N LP <br /> 0.., Maitinp AAdr.0 �,PM.� <br /> Mailing Address City s�.y��� State Zip <br /> CORPORATION INDIVIDUAL- PARTNERSHIP❑ FED A(tENCY❑ OTHER❑ <br /> FACILITY FILE <br /> COMPLETEMEFOLLOM/tNG BUSINESS/FACILITY/SITE INFORMATION.- <br /> Is this a NEY/Busineas L.OcnnoN not previously regulated by the ENMRONMEWALHEALTH DIVISION? YES Q NO):i <br /> Is the an EXISTING Business LOCATION but a NEW TYPE of regulated Business 7 YES ❑ No <br /> BuSiNESSIFACIUTYISITE NAME <br /> SITE ADDRESS - SUITE0 BUSINESS PHONE <br /> f3�ocic 3�}3 ,o) j I-I 2�— LOT$ 2Ca041 e Zta-a NH <br /> STATE LP (� <br /> IST, low aTsv, a'ao^-+r apNanza'r!� ' r 1 <br /> ewx'Fw'.M.• . 77.7,ibr. Eyr _��.......Yom,._..—....�,.�..._:.JI <br /> Mail-Ing Address tlD/FFBREWTtrofn P&altyAdaress Attention_tar Care Of(opdorml) <br /> C3zuPC Dc—,j ��✓t �Y�DanJ 1-sem l7oy� Ul.lP—uc <br /> Mailing Address City S-2-e?( W M AY---,.4 J�-ti . } J� JTZ STA `'A 7JP > <br /> 1%49=9=207y'; <br /> 49 btu"' W' ' 0", K! 4 It M a.n ,Gale orrdn:: J <br /> THIRD PARTY BILLING INFO: Complete if Billing Party is different from Property Owner crFacility Operator identified above. <br /> SUSINM NAME AtterMion_or Care Of (0pboust) <br /> M c_L�t nom- ;;��; Jam=c. �•n t- r ;=�r��1% <br /> Mailing Address I i l �' w \ it,� PHONE <br /> Cm STATE /+� ZlP R`J <br /> Acreu,VrAnnREaer for lfees and charges /TOWNER FACILIT MUSINEW /THIRDI-PARTY BILLING <br /> MLLING AND CoM ince Ac"(AVIS MEteT- 1,the undersigned Applicant.eer ify that 1 am the Ownu,Operamr,or.(uthorb/d Apew�of th[c Rudness,and 1 acknowledge that all <br /> PFWKrrFreS:P2WAj.nP'4 F-NFoxeF.wYmCNAxfp.S sod/of ffouaI yCRAISGM aasoeiatad with this operation will be billed to me at the address Identified above at the Ae:(TX'ATAp1)R9KT <br /> for this site I also certify that all Information Provided on this application is tree and correct and that all regulated activities win be performed in ateordame,with all Applk ble SAN <br /> JOAoins CoU Ordinance Codes and/or Standards and STATE and/or Fin, a L Laws and Requlations As the undersiRned ovmer,operator,or cleat of the property located at the <br /> above faclity'hite addreM I hereby authorize the release of any and all results and envimonmema l assessment Information to SAN JOAQUIN COVMY ENVIRONMENTAL <br /> HEALTH DMSTON as soon W it is available and at the same time it is provided W me or my repnmenhdivQ <br /> Is 'PRINT <br /> APPLICANT NAME SIGNATURE <br /> ! l r �7r C% 'f SIGNATURE <br /> DRIVER'S LICENSE <br /> TITLE (PHOTOCOPY RcoumEm [v(T <br /> `��PP1C x' w tcOur•tfn�OMc§'h'rdceeefog �' t ,'�Dafe - <br />