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08/04/99 WED 10:21 FAX 510 663 4141 uE03Lalt«s va LL.UNIJ ° <br /> • San ,loa uln County ntdiUc Health Services Envimnimerl* etatth Division <br /> .. <br /> FORM lEI-I Op i3tNfv11,'O nitrt lfa>7 <br /> OATS j MASTER FILE RECORD INFORMATION <br /> UNIT IV <br /> a»»ary.•w Lo».EMO yrt Q•�L � -.fJWNEft IQR = ---Y, /A <br /> OVIINER FILE AV <br /> CHEcxrr OWNER CURRENrLYONpcf>NrNF-H <br /> CdAIPCEI� OWINGBUSIS.S_OWNER INF-ORMATION: ---- --_ - _ <br /> .._......._. <br /> THEFOLL _...._ -------- <br /> ........... PMONE .......... <br /> aU31NQ3y �'✓� -- -----— ( / qJ Q ! Q <br /> OWNERNAMC ----L"--- .-----_ : <br /> _F•ne- <br /> ..................... ......... ...._-..__ -------__�_....__._.. <br /> ..... _ .. SaC 5EC/7Nclp <br /> 8U31HE33 NAME(If dlrTCrronf 1ft)nr Qwmer N,'�mJei <br /> �(/S / !�Of¢>'3 O ORrvF.w'S UcEr+sE Y <br /> pwwcn HOME AOORC33'y/, ^�� �7 <br /> Chy �4V � $YATI;� z,p �/SIV fes- <br /> 0wmi;A MnIUNG ADORESs t1fDIFFERENT/nvrn OwinerAddirmisl <br /> Attention:as Cxe 04 (opdon�rl 7 V <br /> Stam ZIP <br /> Maldir.p Addr"s City <br /> COnrgr+wTtaN Q 1N41YIOUAL❑ PAarPIER3MP❑ LOCAL AGENCY COUNT/AGENCY Q STArt3 AGENCY G Eco AGENCY lJ nYNEN❑ <br /> FA MTI FILE <br /> FAciLITY!t1'X' t Itba AEF itT At ' <br /> CoN►PtErETHEFOLLOWING BUSINESS I FACILITY I SITE INFdR4fATION: <br /> uintsd by the ENYIRONMCNTAt.HFxTN OM3rOn Yes C No ❑ <br /> is th.s s NEw Business IACATION not prvvrouslY r eg <br /> yes C No ❑ <br /> Is pt,s an EMSTING 841.13iness LOCATION buts NEwTYP£of regulated Busineso 7 <br /> ausimESSIFACIIITTISITE NAME <br /> SUITE 0 BUSINESS PHONE SITE AOORES3 ` Z:i_iQ `Q V-- J j� <br /> ,-,try <br /> <?` '`" SYIyTL•a - LP <br /> ony- <br /> Atterrtion:ow,Care Of ed0ona/) <br /> Mailing Address if CIFFERENT A-um Facstit)'AOtfnsss <br /> STATE ZIP <br /> Mailing Address City <br /> sic COOS I AP►t# CoMM4tYf <br /> ,a <br /> THIRD PART?BILLING INFURMATIAN COmpJ.. /f Billing PBfiy /..d/ffefel.rfr0�7►Business Owner IdBRUfed above. <br /> Attoraliwr:,arGar•.OT (ovObr*sll <br /> dla31MV."NAPE <br /> PHONE <br /> MailkV Address <br /> STATE ZIP <br /> CITY <br /> gF,EJVNI�QIIR,ESa <br /> for tees and charges OWNER FACIUTYtBUSINESS THIRD PARTY Sit-UNG <br /> III I rNC AN"(-n�IPI IANC'Y 1rK7,a rL.EO[:ML*rr.. L the undenigartl Applicsni,ce"IfY that I am the 0��.(Jlrer�srnr,ur,ls+Aivri:af.1;�of this ItuaanC�,acrd f aclaMs th". l that ail <br /> ilF7rollr FEES. IT.u+LITGc, F.,vFnRCEtlEtvr Qf"rRGFS atrJlur NOUxL I'CHARr;C� as,asted with this nperalisn ­1 be brlled In me at rhe a,tJrr++;de,atified ab,vr .0 hr !rY'nrlvr <br /> 1UnRF.sS ror Ibra „Ir. l iso rernfy hat ad inform■tion pro .,n Ihi.. applleahon i•tnrc and correct; and That aN rcquiarrd dei irne will hr perf�io naam of hr rnth nY <br /> applicable St+t.ln.WpM CUU+ITY 0"inanec C,nim amiUnr Standards and STATE md/er Prpf;tru.Sawa anJ ReCttfaauna- \+the undeni>neJ u,rnrr. p Cr P In <br /> Ioc:+tcd ,r d,r altirve race iry/Mir addraaa. I herehy asthanze the reir,ue of a,n and all re+alts and rnnrnnntental asaesvrrent mfornluiom n. S.�N .IfJAt)UIM C t)UI\fY <br /> FN VIRONMErfTAL I;E�1LTII DIVISION as son its it is avaJahir and At tim++one time d is provided to me or my,repot enraivv. <br /> SIGNATUR <br /> P E PatfrT <br /> x APPLICANT NAME <br /> DRIVER'S LICENSE• <br /> TITLE <br /> D AorxNir+drtq Offloo Pt Icessina Cor"rWed By. ❑ate —I <br /> I Approved By — -- - <br />