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UW22/2UU1 tltl: J8 2YJ'j4btl:i4J;i 5a. rlr{UkIN rLUUN F rHUt f7L <br /> $7i ,OSL[�111W q ter^ xw, �fkC 1 p.�1 'IUIf:, '11_�1I�is 61 E21 <br /> GREEN FORM <br /> DATE -��'OS MASTER FILE RECORD INFORMATION "MFR" <br /> ,uuuvrw Bmasdasr .�-~ •,:, ,.. -�. �..: � , ' UNIT IV <br /> -sari..„ '�" <br /> PW NAP -6 -37 4_ OWNER Flue <br /> OWNER <br /> oMPLETETNEFOLLotWNGPROPERTY OWNER INFORMA7TON! Qa+/+enrrtrox alF HrrnEND ❑ <br /> omm t clnti ✓ <br /> an <br /> / AN <br /> MSEC/TKTD# <br /> Owner Hartle Addresn Z� <br /> � <br /> o.ne MaT.e aml�a <br /> Mailing Address City Sall trp <br /> eotuamrnott❑ aofvmtuAQ_ Panitttiusirr❑ F[b AGBfCT❑ omea�., <br /> FACILF"FILE S 7 <br /> .oMPLETFT/'/EFOuowl/YG BUSINESS ( FACILITY SITE INFYJRpra7TON; <br /> Ls this a New BuMnPSS LOr-ndH not prerlously regulated by CIN Err+raorA Al.HII DlNU 7 YEs'bil. No ❑ <br /> IS this an iam,,,Busil LOCarzolr bet a Ns'w lyre of nvulawd Busivass 7 Yl ❑ No <br /> Bu5reE55/FamliY/SrPa Nawe <br /> ( e, <br /> Sz*s AtsdrASs �I <br /> Ssrne# Bsjazx S pmvdl <br /> scan 's zip J `` <br /> 41 <br /> Mailing Addreu/(DYFFERENT/ronr Fad//eyAddrill Attention:w came Of(aptial <br /> Milling A idres%III STATE ZIP <br /> F. � . <br /> THIRD PARTY BILLING INFO: CoMpli if Billing Party rsWilil eat from Property Owner or Facility Operator fdent,,..,.. <br /> BUst1t65 NdME Attention:dir ,R IIx teprldna/) <br /> c G Jo e Z.LGr's <br /> Mailing Address /?�znt=- STT ) , y—/-j � <br /> a„c a. ©5 <br /> a,Y <br /> r >^ <br /> ' �t,�yYpuNTaoaRESs for fees and charges OWNeR FACILIIYIBUSINE5S THIR13 PART'BILUNG <br /> li na.mr.annr nsn.c 4 thr eedcrs�°ed All aorlify that]am the�Jw�rr,Operar^ry or A.A,nved Arevf^f his Bimetal and I askmmkdse that W Fe 601r FCE, <br /> P6 ITIES,,EnsaaeEa2.vTCNAAGFs alydlM IfdURLT C9AR6i3 associated with this operation will be Will m W al she address IdcntfiN ah^ve sa Mc Amro rADDaFcs tar his vire.1 alae ett4fy Ih°tar <br /> information pr Ill no this applinall 4 leen And wrreets and that as rcYntated adMlties wig bse Perderol In a^e Ame with all apPIll San JOAQ,,,COW. IY Ordinance Codes and/or <br /> shvdards anti STert ed/^r FYiMtPu.Laws avd ReeWadom. As We mdenigurd owner,aperatnr,ar a6ent^f the property IavRd at tlw vmjve rosily/tire vddros,1 hereby..l Ill'A.^f <br /> any and alt I—Its and envlronmcntat se—meal iarwmad^n in SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DIVISION as stun as It is anitatle and at the same five,It 6 prendcd in <br /> rM w my rl'promiative. <br /> RreBE PPinrt <br /> APPUll NAME / `T c SIGNATURE <br /> 011tr 'S LICENSE 7E <br /> ompr <br /> TITLE �`>�-il'� (ilHorPI <br />