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vu-1 l�—I`-�`-�ti 1 YJ=GC7�+1"� r rcut•� ! ��A� <br /> f f.. <br /> Maw {FSsmss(Rttrtsloosrvsas7} <br /> DATE LL�;1 i� �9at� MASTER FILE RECORD 1mr-O MTION UNIT IV <br /> OWNER FILE <br /> COAPLETE THE FOLLOWING BUSINESS OWNER INFORMATION: <br /> A►ECufa OWNER GLRRExrzranFrttrrKn+EtiO Q <br /> ? Prot <br /> OWMMNAME <br /> _ .--—__-_._.._.—�......_--�.'J Sot SEcf TA�t IQ ti • <br /> EUSlW-=NAME(If diftrenf a30%wner NST <br /> OWNER Hama A009ESS � �Z24 �.� t? p � "`�j IZ , �f� l� ° QWYF"L cm3E! <br /> STATE Q ZIP <br /> • ,.rs <br /> OWNFRMwL'N6ADORESS (IfQ/FFFJ7El�T}!'cMlOfr�eritd011lSSl A !>o0et_ly��CaitsvE (oy0or>a/I <br /> • � 1J�v F <br /> MAN <br /> ZIPIrloiling Addtssa City <br /> JRpOtrATaCk Iwt?Ivtt]ttu>_Q PAR'MERSMP Q LOCALA4E7>!CT Q C,DtI'r Ar.+FIc't'Q STATE A6ENCf Ftp A¢ENCr C?TlIER <br /> FACILITY FILE PF <br /> F <br /> _ Y <br /> COMPLETETXFFOLLOWIIYG BUSINESS/ FACILITY I SITE INFORMATION: <br /> Is this a Mr:w 8usirmms We%TION not qty ragttlatad by the ExvwoKMrjff LHE&&T"oMstow? yo C No pQ(/ <br /> Is anis an emsnNG Business Lo"'now but a NElar lym of r egutated Suoirmm? T <br /> 8usawEsslF^=U- 'fSt7E NAME C+ G4� i� L <br /> �+wJ't�l T 1 <br /> i1nIIRESS ()� Sum* BUSINESS PFIONEi�, ' <br /> v .J ` ��`�t MH t� 'L►1 4ti�. a��q .'i i 3 1 .� <br /> c:rr srA Da <br /> >�c�'�"t�.a►- - C A � <br /> r .ex: <br /> w MwTing Address ifDIFFERENTfrtvnFadUlyRddrt:ss ; Amerttiort:or Cars Of(optfaM# <br /> M.uiiitrp Addr8w City <br /> i STATE i zip - . ..��.. <br /> THIRD PaEtT1f BiLLi1[G IKFORltATiOtK: ComfsleA9 if Billing Party is differerrtfram Business owner/denied above_ <br /> 3usiNESSN/WE �� n /� � � A "�S�b aCYI�r*�•L+ � - -- <br /> IAaiiing Address L V <br /> STATE 7i .. <br /> for feces ane!etraeges " aRMER <br /> Fniam!&s ess THIM PAMY BZLJNt3 <br /> BILL C�.7Yn CO . ��A otvLEDc«��T I.the emdersi�sed Apptit�et�4tbac I am the Qw+,�Clpoaw.,ar.t�.eharrired.t�eat ort�is gtmines;and Iadmowtadye unzs siI <br /> P=Wrr t7:E3, ft-V tL7= F-Mft=N=-7 QWG=aedlor NOMMY C--AGES=w ted with tbie operation will be billed to we a the addrew idenurwd above as.the,{CCP�JM <br /> .{ Cor this site I also ctstify thas-ad informadon pmm idod on.chis appliodoo is trw wed mrreat:Wad that ail rocutand aemvitics will be performed io armrdznCe with 211: <br /> applieabie Sa.`t.laAQM CotrNTY Oedinmwo Cad.at and/or.Standards and STA78>mdlor F=jtAL Laws and Rn"am As the undersigned owner,op�stor.ar agat of the PmPerty <br /> Io=wd u she abort raeilityisice address. I hemby wthorku the rete of say sod sII rowan.and eavironmental aucwc tt inforatadnn to SCUM J0AQtM( COLM Y <br /> E��'^�E`tV[EYTaiI �j,THDIVISiOflt>swonaskisavailabkand antIke sametitoeAisprovidedtomearmyrspeesentarise- <br /> PLEASE PRINT. <br /> r SIGNATURE <br /> A�V6CANT NA►tiQ <br /> ORrvBR•5 UCEN _ <br /> 'nTLE "c <br /> ,, •.xfti <br /> kM <br /> � <br />