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2001 10 : 134 CON%" EARTH TECHNOLOGIES � No -5040 P . 4/a <br /> y <br /> ir• " vwr+ <br /> GRUN FORM <br /> I)ATE MASTER FILE RECORD INFORMAT10N "MM" <br /> snaceoaaeaeronfhnaeroNE.v - UNIT il/ <br /> OWNER FILE <br /> CuMPLEW IHEwccOW.IPROPERTY OWNER INFORM.4770N., i vMECX F OWNER CIVRR5ynratr UWrMEHLI <br /> PFMPMTY OWMR PHONE <br /> NAML <br /> l3ut;,ttM NAME Sac Sec/^fax II]# <br /> Owner Home Add.eas `�/`f rF L/ DRY s LxcrosE# <br /> y $rarE ZIP 4 S7- <br /> Owner Mailvv AddhM <br /> i <br /> MaJiing AddmI City Slato zip <br /> TYPE OF OWNERSH P <br /> CORPORATION❑ XNMVnuAL PARINERSy1LP❑ Fra AGENC!❑ OTMthi❑ <br /> FACILITY FILE X01333 <br /> COMMETFTHEFOUORTNG BUSINESS I FACILITY'J SITE INFMNA7TON: <br /> IS this a NEw Busiw! t LiocATiotr not previously nagulated by the ENVIRONMENTAL HEALTH DZVM40N? YLs ❑ No �] <br /> Is this an Ex wrmq BUSMeas LOCATION but a NEW TYPE Of regulatAd Business 7 yes ❑ No ❑ <br /> BI,SAJESS/FACILITV/$t'rt NAM <br /> $IYEAODREM r/ SUITE,7 131t awk_ss NONE <br /> CIYY STATE Mp <br /> //,,a r- <br /> i Off <br /> Mw11ug Address 11 QrFffAt1�N7 ftm F.rddlffyAddrem O Attention-ar care Of(epbbual) <br /> MailingAddm65CIiy O STATE zip <br /> THIRD PARTY B(IJLINGIN�O; C i eteifBilling Pariy isdiTereatfrarrlPropertyO�lnerorFacilityOperator idenOed�6o�e. <br /> RhgIIt�NAMir AUiandon:orCare Or (Ap6anWl) <br /> htailillg Address <br /> PHONE _2- . <br /> CrFY STATE <br /> ArnuWAbbF=6 for fre and ch$f,9$8 OWNER FAGILJTY1BLl51NESS THIRD PARTY eI1 LINO <br /> BrUIMG AND CompuArICE ACKNOWLEW;MENT: I,the uat 1pigncd Applicant,terrify that I am lice(buns',Operator,ar,4xdrori?dAgent of this Business,and I acknowledge Oat'all P2MWT,F)FEs <br /> PFN4ju i:.'S,ENFoflcrm&W QMGES and/or HoCaLF QI sssociatcd with this uperalion will be hlilyd to me at the addrese i4endfied above as the d2ZOaNq An__ DF.W ibr this sits X 2.66 M!*that <br /> nil informetwn provided on this appli"tion is(yue and correct;and that all regulated oetivitics will,be perfortaed in accordance with ad appliuhie SAm JoAQUtN Cpt,-rrrY Ordtnaoce Cndes and/or <br /> Standards and Sr.aY>;and/or Firm Ai.).j and itettuiatftkI Ai the undcn irprd owner,operator.or ageut of the property located at the above facRity/lite address,X hereby autb4rizc the rrbI of <br /> auy and,all results anti environmental xmm- nimt infnmotion to SAJN JQAQMN COUNTY EN VIIl01 NI)t NTAL HEALTH DIVISION as soon as it is av=Wple and at the suwr time itis provided m <br /> The of wr rrprewntauvc. <br /> ptEME PMT <br /> APPLICANT NAME ..;NATURE <br /> TTTLIE DRIVER'S LI E* <br /> /� (PtiOTOco <br />