Laserfiche WebLink
4-20-2001 03:38PM FROM TO 19168531860 P.02 <br /> „♦A',yyy, ?+,e[ullnNvu uut:MY {� 4�{I11 G'u1u� yC:4 V14 1fY11 V{11 C< <br /> DATE MASTER FILE RECORD INFORMATION "MFR" GREEN FORM <br /> r <br /> 1416116 aktru ENO we ow. <br /> OWNER FILE <br /> '+� <br /> � UNIT IV <br /> COMPLETE THEFOLLOW/NGPROPERNOWNER/NFORMAr/ON. CWcKIFOWNER CuRReNnyoAiFxEwtrnEHD � <br /> PROPERTY <br /> -r^ `� n p <br /> OWNER NAME PHONE <br /> (�1�.�j Pf}��S Z ��0-2 C170 <br /> ANN w <br /> BUSINESS NAME <br /> SRFEu/A i n C . Sod$Eo/TAxIDp <br /> Owner Home Address <br /> DRIVER'S LICENSE O <br /> city STATE 7JP <br /> Owner Meiling Addrew ' <br /> Mailing Address Cityf/t0 <br /> r�(( �-tk� .P�n �E.4sgd7or✓ state �,y ZIP�4BP 1 <br /> CORPORATION & INCIVIDUAI,❑ PAWrNERSNIP❑ <br /> FED AGENCY❑ OTHER <br /> COMP4k7E7NEF0LL0W/NG BUSIN FACILti FILE <br /> tv{ry{r <br /> r° . . .0 REF: :al � ?' 4q <br /> HS3I FACILITY/SITE/NFORMArioN' <br /> 1611116 a NEW Business LOOAnON not Previously regulated by the F"wRONMENTAL HEALTH b{VIsloN Z Yah,� NO <br /> C:17 <br /> Is thm an Eh18Tin6 Business LocAnON but AINEW TTRa of regulated Business? Yrs Cl No <br /> BVSINessIPAOIDTY(SITe NAME Pc/ -'StyvTLy 11NA%%tfqf0 <br /> $ITE AOPRE$6 SWTfi# Bg81NF98 PMONE <br /> -14Srecis7- f-r ce x4�A-c A,,x o ,PtnA <br /> CITY ,��y <br /> STATr//[ 21P Y <br /> 611 15,NO <br /> Mailing Address yOIFFERENTfronl FaclIW Address Attention:or Care Of(optional) <br /> Mailing Address City STATE zip <br /> 1' C� f ;fes <br /> APN r., <br /> air v.Ys+mYlm� <br /> rXIRb PARTY BILLING INFO. Complete if Bailing Party lS different from Property Owner or Facility Operator idenlifedabove. <br /> BuswESS NAME �EO Attention:orCDre O( (optional) <br /> TWWA/S -Zll/c. pof� j.c <br /> Mailing Address 3a�S— .W. 0.5 714,0k AV Vc- Sf/S7e: PHOMrC 1 <br /> CITY O COy2D0 A' - srATrC'/1 LP <br /> 49MA —APUEss_ for fees and charG <br /> ger OWNER FAUTYBUSINESS T[I �AIRTY BILLINGb <br /> mY�eeeee�yl <br /> {ILLING AND CDAl11.IAN<`r ACKNO\VI LIN`MrI .. 1 the understened Applicant,emiry that I gin We Ctwn¢r <br /> '{tRy/rrFt:C$PtiLU.rae'EVPt f OPrra(or,or Au(h"Itad Arel of W1y U dII,,,and Iacknowledge(hat All <br /> Nll I"ronnaijon(1ST ld al o nbig ap illeation14 A6yeeEAlCd with thu oP<ea110tl will he billod la me at We AtldrC.iy ideintlrlcd Above AA the ACrOVAYAnRREu <br /> ar QUIyhC. i AIYO Carina that o la forttlor Sl ander l On tills tlppgg1100 iY araC and Cornvti and I441 Nil regulaW aetivitim will be perforated IN ACeonlaneA Wilt)All appilCAble SAN <br /> (QVC IN COUNTY Ordress, I hmb and/or Slander and STATE and/or FtoERAt.lAws and RrgulAtic," AY the Madenigrmd awnv,operator,or agent df l"ch.proilAll PPI10d of AN <br /> Bove facllltylci[e address, 1 hereby aalhonae the rehlae of Any and all MAIM and envimn,,,Ud ayyaament inroe/Aliion to SAN AUAQUIN COUNTY ENVIRONMENTAL <br /> tEALTIt DIVISION as coon ON It's available And at the name time it is provided to me or my npraentative, <br /> � ` PLFd$E PRINT /J O <br /> APPLICANT NAME �aN ��� SIGNATURE �Q <br /> TfTLE 'T C7LOLG�=`/S"r bRIVER'S LICENSE It <br /> (PNor.'r,w2F2U ser I <br />