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11/0112000 13::0�r4y� 209468P343 �i FI[F?�T/H FLOOR yy PAGE 03 <br /> fir"^ ' : " ..�Y'2i' .. '"...._ n..�,�...�.(V►� tip'++I ir"°"-,-,^ .. ti - - <br /> GO GREEN FORM <br /> OATS 4 l y p� MASTER FILE RECORD INFORMATION "MFRS' <br /> sN.em...es ana Faso Vie r "' :�. _''^r`•ir' '""."",� ,,�u r- '''+ •.1 <br /> UNIT I Y <br /> QINNM FILL Ov <br /> t:NE6CIF OWIVEii Yw+r�nrttrmiEHD ❑ <br /> ;OMPLErg MEFQLLOWNU PROPERTY OWNER IAIFORMA730M. <br /> PROIAMMOWWA <br /> ttstltFss NAME y r 5W sec/Tom M# <br /> Ba 1�E n-1 �4 sli-&t S <br /> IV <br /> Owner Home Addy � A n� ptavm"s License# <br /> }�o d� L l- �f C.1i iCi l=-•C�As D <br /> city i STATE"ill ZIP <br /> rz.r�� � <br /> Oyrtrer Malang Addrss <br /> Seale Zip <br /> Mailing Address r+hr <br /> ThvE OF <br /> COWIORATWN l0.IW01=UAL pARYNW❑ pPaA6F1scT El o,++ae❑ <br /> FACILITY FILE DOIalp <br /> %WE ' _ . <br /> ;7 mmmTHeFouowavG BUSINESS I FACILrI'Y SITE INFURMATWN- <br /> 1s this a NEW Business LOCATsaN tot prevltsusly rEguiated by the ENIRRONmwA4 fit'•ALTN Dat=N 7 Y ❑ No ❑ <br /> 1s tills an Ezsmo Business LerATtON but a NEW TYRE of regulated Buess sin7 YES <br /> s [� NO <br /> BUSINESS/FilMM/SMNAMe <br /> ti - LI U �f, 1 <br /> SMAtaD.Ess sZ'•� vote 0j �d,�t,0 Svc# $U�P1SOrtE <br /> iJtr�t STATE ZIPCA p 7c� <br /> a p DIS7NES ALOenbwt:ew Care OF(0p6ianal) + r <br /> Mailing Address r7FDlh7.71W7 ft—FadWAWm- <br /> Mailing Addrm My STATE zW <br /> THIRD PARTY BILLONe IrIo;"COMP/Lo a if Silting Party is d/flerentfrofn Property Owner orFadlity Operator idenfflWabove. <br /> gusttigs NIgME Attetttion:crCare Of j <br /> �itio�� 4 CA "15 wl�--t-t- LiA 'Ldni LAN <br /> mailing h1dress 16-7 3 KA 2 nn c, s j� ��� PNONe <br /> STATE [7 _ G <br /> . Cr" 12Vrrs� <br /> i for fees and Chargm OWNER FACILTTY/BUSINESS THIRD PARTY BiLLNG <br /> iLUNG ANTI Mvt.r wT.xn Er , t,rhe mdmsipr,ed Applicant,ccytfY ibat I am the awaer Opdatar,or ARMvMrd AgcW of ttds Rudnaa,and i acldmsr p that ail PEJ-r <br /> PEnutrrssti F,vl acncEN7CNANW malar SORLYCRARGO assaaiated vtitb this 0pera6on will be bMcd to me at the address 1doodriied above a:the AGcwtrrrr.tbaRBss for tins rite. I ahto certify tont <br /> inforpsatiao provided ou chic apptieadon to tate and correct•,and that an regulated activities wM be performed in accordance-ith all appvcabie W JOS qum Cotlrt'tY Ordinance Codes and/ <br /> Standards nod Ss►rs avatar 1 Ueae u Laws Mad Reywiadamt. As the uuderslgncd owners operator,or Moat at t'dc prooersY located at dic obm f dUcyltitc address,t hereby andmi a We reltase of <br /> gay and 41 res"and environmental asocarnent iofoemadan to W roAQuIN COUrvTY ENVIRONMENTAL RF.ALTkt DMISION as Soon as it is available Mad at Otte latae Gme it is provAdcd <br /> me or my repremotive PLEAN&y L injr,�— <br /> w Panel' 1 <br /> APPLICANfr NAMESIGNATURE I ATS A '� /,\, A O�U <br /> DRIVER'S LXCFNSE# !A 6 '(�Vim1 l ve, <br /> Tru - � ��-$• i Sr V fJ�\ry (PitarrornPr ) <br /> ' .. •. Sr <br /> ..Yn.r,r. ' F• ,.Gt:','wf..�''�""`'�ww��""�.�.."�"y. 'Ynr. <br />