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07'26.'99 14: 13 FAX 209 46" 31 FOWiARD INC. 2002 <br /> GREEN FORM <br /> DATE MASTER FILE RECORD INFORMATION "MFR" <br /> a WED MEAS FOA END naE dine UNIT IV <br /> OWNER FILE <br /> COMPLETE THEFOLLOWFNGPROPERTYOWNER /NFOIRMATJON. ONECKtr OWNER OVANTERTLPONnLENYTHENO <br /> wEew PNaNE� <br /> O <br /> A! Y of <br /> Buaetess Nae Soo SECITAS ID W-12- <br /> lG O_12.7Y21'1OWWHomeAdOmea ay ���/ `+CJO <br /> cityCir Com/ VO r STATeA ZIP 9�D/ <br /> 0%mr Meiling Addre. <br /> f.,.« <br /> NatRng Address City S <br /> 1=7, <br /> ORATN)N INDIVIDUAL PARTNERSHIP171 FED AGENCY OTHEP <br /> FACILITY FILE <br /> : ,. .'.. ... ,, `•♦:rr sus < .,... I,..:- :i .i : :,-n '.o,- .. :' a Pr�'tr ...-.."r ice°' :II2� j'-+`s <br /> COMPLETETHEFOLLOW/NG BUSINESS I FACILITY I SITE INFORMATION: <br /> Is this a NEW Business LOCATION not previously regulated by the EWIRONMENTAL HEALTH DlvatoN 7 ves ❑ No �aQeay4y{1 <br /> Is this ml Exte rwas Business LoGATION but a NEW TYPE of regulated Business? YA NO IfJrP <br /> . BUs1NESSIFACIL1TYiSiTE NAME /j/ —/=.:7 /�� ��qN y <br /> SITE ADORrdse (�,T9'KT� w/}1 S( Zl�i/ B;r <br /> CnY 517TE zip �40 <br /> f -161M <br /> Mailing Address ifOIFFERENTfrom Faoi/ityAddresa Attention:or Care Of(optional <br /> Mailing Address City STATE ZIP <br /> -4a .W1 .. ,_'.v: h�, <br /> r✓,.sIi <br /> THIRD PARTY BILLING INFO: COmp/eteif Billing Party is different from Property Owner or Facility Operator identiffedabove. <br /> BUSINESS NAME Attention:wCare Of (optionaif <br /> Nailirq Address PHONE <br /> CITY STATE ZAP <br /> NT for fees and charges OWNER FACILITYISUSINESS THIRD PARTY BILLING <br /> BILLING AND COMPLIANCE ACNNOWLEOCMCNT: 1,the undenigtRd Appikant,edify that ,or AarhorizedAgolt otthb Business,and I acknowledyk that all <br /> PEEWFER,PEW TIES,EVF0RCEIMffCMtX(as a ad/oTH0VACYCHARGet seasoned wNh this operation will be MTkd to meat the address ideatilied above as the AmDu"�fooKas <br /> for this SOL 1 sbo testify that off Information provided on this appantbn M tree and entreat;and that all regulated adhilles will be performed in seeardwave with all appikhble SAN <br /> JOAQUm Coutiry Ordiaaoct Codes and/or Standards Rod STATE and/or FsarRAL Laws and Reguiatim. As the undersigned owns openter,srafgwt ottha property bn1Yd M ik <br /> above 4dRly/db addreu, I hereby authorize the release of any and all results and environmental asseamut Inforolatbn SAN DOAQ COf1MV ENVIRONMENTAL <br /> HEALTH DIVISION as soca as h b RWibble and d that same time it is provided to me or my tepreNstati". , <br /> PLEAY"INT <br /> APPLICANT NAME _ r , S,IiiCL.(Qt�wJ 31GNATUR <br /> TITLES <br /> 'DRIVERUCENSEM �.�rp2 7� <br /> \ DRIVER'S REIIYIRMt r/vOdtP <br /> z 'd WOtid Wb'99 r E 666 t-EZ-4 <br />