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04-20+2001M03:38PM FROG t TO 19168531860 P.02 <br /> ,...-=...r 'u.v '.: .,,�,}l••1�+--� .L `L2�.�.wLIs11 Y1,-1 .Vitt. «:l �V'JI��L7Y'LtVi.1..:r:a..w..v.....t�wut:�c::..w <br /> DATE MASTER FILE RECORD INFORMATION "MFR" GREENFORM <br /> 5lkaERAs&eree FNP vac Ora. � ' <br /> UNIT IV <br /> OWNER FILE <br /> COMPLFTETHEFOLLOW/NGPROP RTYOWNER twolufAr/ON: CHECIOWNER CVAWNnroNpt9wirnEHDQ <br /> PROPPATY PNONe <br /> OWNER NAMc TvD,G PR/2H1>Is ( 2r)11-617-2078 <br /> A� ea <br /> BUMEss NAME ` <br /> Sr4FEeUA rl C SOC SEC I TAX 10# <br /> Owner Home Address - <br /> Oql VERS LICENSE# <br /> C City <br /> SrntL ZIP <br /> ;Owner Maanp Add. <br /> Mailing Address City S' f0 TdAfP�IT)l.-� Aisr,lY z,P <br /> �,q <br /> —T <br /> CORS PORE A�TI�ry INOIVIDUµ❑ PAWN IPE3 FEDAMwc; ❑ OTHER❑ <br /> Yb FACILITY FILE <br /> !tfi_Ata tyT{Y�D"#ft! < lI;Y Yr�Yri�.eY°i i a«YG,v a 'n oc <br /> ReF'10- - �«st acouerr «�-� <br /> 004J 7FTH 'FOLLOWING BUSINESS/FACILITY I SITE(NFORMArloN.' <br /> Is NIS a NEW Business LOCATION III Previously regulated byft ENVIRONMENTAL HEALTH DIY{I 7 Yos, NO [I <br /> Is thin an Evarma Business LOCATION but tt:NeW TTPE of regulated B sinew 7 , Yes p No <br /> BwmesslFAcauTr/SITE NAMe �Lf�ol GLS ��'V <br /> P/c{'s�rYT1-y vNlk�uv�e <br /> III AOOAEaa SUITE BUSINESS PHONE <br /> SLC-S`r /'4STI6 lylsT x/44 s le6jr) ,SNE/'efs,, Tey <br /> Cm <br /> STATUI ZIP <br /> Mailing Address N0IFFERENrfrom Fac1116,Addrass Attentlon:or Care Of(opttonat) <br /> Malling Address City <br /> ,gSTATE 7JP <br /> paig <br /> 1 Cain'.. `�, •x :EAPNl1 �.n <br /> rNIIiD PARTY BILLING INFO. Complete ff Billing Party is different from Property Owner Or Facility Operator idenNfled above.^ <br /> 8usINE4SNAIA9 �y�0 AttenIorCereOf (optiwrrQ <br /> Mading Address 36 pIPaSPfir l�?(dF <br /> r�•� 4 SusrE fro P"°"�1/�/ �5-3 oxo r, <br /> CITY i� G o Coi2Do A <br /> STATE G/I ZR y�—,/76 <br /> ARRRL/ATAoIyReSB for fees and charges OWNER FActulVBUSiNESS 4:W:1fAR7YBa.LING <br /> TILLING AND COMPLJNCA ACRNOWLanrmr—. 1;Me uudemlgnad APPUcaul.ceniry that I an The Owner,O1//1Y(or,orAvdlorlrrJAFrn(oPthis Uwhltar,and I Acknowledge that all <br /> 'IMUT.F=.PANALTlEr.EVF(J KEdfeNr Qz4RaET and/or aOUALYQmm,CEy associated with this operation will be billal To me at the address hindised above Y the 4C%'WNrAl,Pn1j <br /> or thb sfte. I Atso certify that all Inronnndon provldgl on this appgalloo b true and correct;and that erg regulated aclivhim will be performed in accordance with All applicable SAN <br /> OAOIIIN COUNTY Ordlaaoce Codes And/or Slandards and STATE and/or ALUFRAL IAws And Rmulautea As the YYdereignad owner,ppeMlor,or agent of the properly located et N< <br /> Bove facility/site adoreµ I hevehy anlhoriu the release of say and all results and anvlronnwnyl a nancetnt inforaullion to SAN JOAQUIN COUNTY ENVIRONMENfAI, <br /> IEALTII DIVISION As goon ne it IS avalhlbN had at the same done It b provided to me or my rcilm entadve, <br /> + <br /> PLEASE PAINT <br /> APPLICANT NAME SIGNATURE <br /> TITLEC` OL.GZ=/$T DRIVER'S LICENSE# / <br /> _fPifOrnrnwnEOtnaenl <br /> PCRYefF61�.i#iv�i.'a3.�1T v, ;: ,. .. u."nlin'.uOflIO�aN��Odess ,400t sM �:.u, ;toy <br />