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_ .._ D 3 <br /> . �' FIFTH FLOOR � . <br /> 11/01/2000 13:04 2094683433 FIF g <br /> nil: er�afi�_ -Ip �':;:� : <br /> DATE DEC r '66ORM <br /> • I� !) IPS MASTER FILE RECORD INFORMATION MFR" _ <br /> IRONM - TNIV <br /> a,yyp...0 eu ENpael O,aY aairraexn, �;y. �, `RM <br /> OWNER FILE <br /> omxEmTNEFoLLow NG PROPERTY OWNER INFnORNATION.- owneR a cvErnror�ewm,EHn <br /> PRopea rOWNPA PHONE <br /> NAW K-I ewAnAj ;" a I (z0C)l 2SZ0 <br /> ray MI au <br /> BustNEss NAME Soc SEC TA Ip# <br /> LI.� rl• �A&pwi <br /> owner Home Addressq ' VCS �` ` _Q Drt1oEn's ucErn'Ex <br /> City ,rR STWE CA <br /> /� 21P <br /> Owaler Mamma Md �•r� <br /> Mailing Address City <br /> Smote 21p <br /> DwFq <br /> CORPORATION❑ INIMIDthLL ir <br /> PatmAeRsa�❑ FED A6FAGY❑ O\tIER❑ <br /> FACILITY FILE <br /> �p I <br /> ;17MPL£TETHEMLLOWNG BUSINESS/ FACILITY SITE INFORMATION. <br /> Is 4115 a NEW Business LouttDN not previously regulated by the ErMRohmei me HEM7rM Dt ON 7 "res ❑ No ❑ <br /> is this an E> mal Business LOCATION but a New TYPE M regulated Business 7 VPs p No ❑ <br /> Bus[Nt55/FaOLRY/SITE NAME <br /> SREADOREss sum# UU51NEs PHONE <br /> Qtt STATE 2ID <br /> Mailing Address,7VD TAMfrvro Fac(htyAOdress Attention:or Care Of(ophuns/) <br /> Mailing Address;Cky STATE Zm <br /> KIC _.. _. Zv�}•. araC+ <br /> M-11 <br /> --� ..Iiw—i <br /> THIpD PAH'ry BILume.INF0. Complete if Billing Party is d/fferenf from Property Owner or Facility Operator identified above.ey. <br /> BUSirffSS NAME Attandon:orCare Of (glPh;xWJ q:I�u <br /> M 001fa-Lice-flLz a A c <br /> Mailing Addresti mo f.o c-*Sr aivwtew 'bMvt PWM' 7y� <br /> Caw <br /> SAPJ 3co.NAdG 146 <br /> A[[f'JI/MAODVFcc for fees and charges OWNER FAciuTYIBUSINES5 THIRD PARTY BILLING <br /> a ,NC Nn nM 1 L ACKN(I WI FDGMEIr"C: 1,the andcrtig ed Applicant,cc Lily that I am the O.Mer,Operator,or Aatbmited Ag w of min I alncs,and t aclmowledP that all?e air FEES, <br /> PENALrrAS,ENFWt:E%#ixrCHMrff5 and/or f;OVR1FC}LI W associated wilh this operation will be blUcd to me at the addraas idendlied above as the ACroD AWPMS for this site I alae«rtify that all <br /> ioforpmtion provided on this applieadnn Is Ouc and mmol and that all regulated activities will be performed in accordiaas with all appikobk SAN JOAQUm Cotww Ordb,anm Codes andlor <br /> standard,and STATa and/or FEDEW Luna and Regulations. Aa We upderdgned owner,operator,or avert a me property I—rod at the Pbore fadery/sift address,1 hereby audmrue Site rekasc of <br /> icy and all retain and environmental asecssment informadoe to SAN JOAQULN COUNTY ENVIRONMENTAL HEALTI-1 DIVISION as soon ss It Is available and at the same Coe It 1,provided w <br /> me or my repteacnrativs. <br /> RF.C/PRD1T <br /> APPLICANT NAME �� `� -. • �Q� SIGNATURE �� �_ <br /> ETEQ <br /> DRIVER'S LICENSE# <br /> TTrLE <br /> f ^�)ll(CDr� o` Ff r(A e-SAV:CTs(_tv\E+2(PHUDCOiar MQUiRED) <br />