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i ice..._..�:� ..:::..f_.. .. ....f. .....r K... <br /> fORM (EH 00 1We vtsEDO6HHl97} <br /> DATE MASTER FILE RECORD INFORMATION <br /> S: CED ARES F`1D �OEOMLI aI �• • r » UNIT IV <br /> �3 OWNER FILE '4 ) 9 o2a <br /> COWL=THEFOLLOWINGBUSINESS OWNER INFORMATION: CHYECKIF OWNER CuaREmayoNHLEw1rNE1DJjQ-,1 <br /> ................................................................. <br /> BUSINESS PHONE <br /> z <br /> OWNERNAME ------------------------------------------: <br /> .................................... <br /> . <br /> ........... <br /> ..................Fnt........................................4f.............................._................(.aal........................................ <br /> BusmEss NAME(If d/fferenl from owner Name) D' Soo Sec!Tax 10# <br /> ' �n 1 C ✓ <br /> OWNER HONE ADDRESS f� QflIVEA S LnIC[NSE <br /> city 1 lJ J�L�JJ .c.� 1 (ll /// STATL— i ZIP `-'► � <br /> C,WNER MAILING ADDRESS (i(D EREW from Owner Address) Attention:or Care at �optYona# I <br /> Mailing Address City State Zip <br /> CORPORATION INDIVIDUAL C PARTNERSHIP L; LOCAL AaeNCY❑ COUNTY AOENCY 0 STATE AGENCY❑ FED AGENCY C OT.C <br /> FACILITY FILE <br /> _. ..,, __'_,. •_.i.,i'c:u�i�"F�ur.u+ -u 'n :c-:g: ru.. 4 r.�r '+r� Y 1 j 'r _ <br /> COKPLETETHEFOLLOW/ING BUSINESS i FACILITY I SITE INFORMATWAI. <br /> Is this a NEw Business LocATIoN not previously regulated by the ENvIRONNENTAL HEALTH OIVISION? YES Q No <br /> t <br /> Is:his an ExianNn Business LOCATION but a Now TYPE Of regulated Business 7 YES No <br /> I I <br /> BU81NE6&'FApLrT'Y131TE NAME _ <br /> SITEAODRESS SUrTE# BUSINESS PHONE <br /> ��� l �� �-�! Lin ►�� � <br /> CITY ST ZIP <br /> Mailing Address ifOIFFERE)VT from Facility Address Attention_or Care Of taptional) <br /> MaNing Address City STATE ZIP <br /> ,, _ �-,Gi�T1n1NRXF[�' z'r........� ..' : _ �. -i:u. `_: •. .... .. �� <br /> THIRD PARTY BILLING INFORMATION; Complete if Billing Party is different from Business Owner Identified above <br /> .............. ......................................................................................-............................................__............................................... .......... ..................................... <br /> BUSINESS NAME I� r [ Attention: or Care Of (optional) <br /> Mailing Address rn, l r. VQ PHONE �I <br /> CITY 1 STAT ZIP���IJ <br /> Accob,NTApoRFss for fees and charges OWNER FACILITY/BUSINESS THIRD PARTY BILLIN <br /> BILLING kND COMPLIANCE ACKNOWLEDGMENT. I.the underigned Appiicant.certify that 1 Am the Owner,UPrxator,or Awhorized.-gent of this Sttsincss,And 1 ackno.Acdge that ail <br /> PFRART FFF-V.PFNAI i fF.ti.EA'FORCBkfE,,,T C/7/RGF-s:Ind/or HOUR.}"C IMRYiBS associated with this operation will he billed to meat thea ximtified aborc as the ACcob'tiT 4DnRE.ss <br /> (or this Sae. I Ricn certify that all information provided nn this application a true and correct 2nd that all regulated 2C."n, performed In accordance with al;Hppicabie`AN <br /> JOADt1IN COIN ry Ordinance Cndts and/or Standards and STATr and/or FEDERAL Lawi and Regulations. As the undersigned, er�nttar,or nttent of the property located-At itre <br /> above facility)sit,address. i hereby aurhorve the release of any and all results and em ironmental w%se_ssmenr intormafion 4Cf J A0(T CnUM1�' F,N%-IRONMG.N'TAI. <br /> HF.AI,TN DIVISION ns soon as it k available and at thesame time It is pmvioed to me or my representative. <br /> PLEASE PRINT, <br /> APPLICANT NAME j � ✓ 3IGNA > j <br /> AA <br /> DRIVER'S LICENSE fF <br /> TITLE r^jam Ll C TT V o,nrnr +� acninvrnt <br /> �pmytsd�q= r' I ;Q'i;if� ;: y -- 'lkariislurttrtq�3fli"c'el�t�cee>sing�'+oCTtt�tiFtri3tE��' y�.` ,•; bat�ai�,"- �'�.� J <br />