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• '.." r73 �� e'r �Iry;"., <br /> DATI: lid GREEN FORM <br /> zS 0. MASTER FILE RECORD INFORMATION "MFRrr <br /> owON`acY UNIT !V <br /> OWNER FILE <br /> PtETF77lEPo[COLYJIYG RO O N <br /> PaOPDetyD1ivFORPm7roft Cwwr OWNBRi ClUbEaMraat ,Ea/N�tio <br /> �pt <br /> ONE <br /> e '�req <br /> XAwe �' Flat1. )K0 Y <br /> BtlgtasE Nate .. -. - .. <br /> Rho <br /> sxsEC(TAE I�1 If <br /> Oianer Nome Addtesa <br /> G DwvkR's LtC,ry�s <br /> Clty <br /> Owes wtllao Addeer CJ I <br /> Mailing Addreao City <br /> Smhe zap <br /> aYr�of <br /> rna..�.n.wi❑ awnnn.a ie� e.n...cocuro❑ I <br /> _ - y , <br /> Ia this a NENBusiness LocAntiN not pmlouaiV mgulaD d by the ENMONMEJRAL NeALan OEPARTMENi1 <br /> Ye=N1 <br /> Ta Ihl9 an E;OS'ratO BualnRs9 Lounms flat a NEW Trac of regulated Buainefc 7 <br /> ,�qe /� (� YEs <br /> ,ssTEA JP II IML P � S A P� (1��-h.d(Ne W nk e�n 10ti ,� <br /> //D N. <br /> SIIrrEfl 64+snIa.,PnaNe <br /> cmSTAIIE <br /> nC y iIM <br /> Mailing Address iIOlFFEIiEN>'Irrom Facl/ItyAddress ' <br /> Attention:or Care Of(opWna/) <br /> Mailing Addre�city <br /> SIAI ap <br /> �. b <br /> THIRD PARTY BILLING IN>=o; Complete if Billing Party is difPefent from Prop"peaty Qwner orFadlity Operator ldefaG'fredabove. <br /> Attention:wQm of (nodnat <br /> Mailing Address <br /> PHONE <br /> Cr" <br /> STAt <br /> for fees and charges <br /> OWNER FACILITY19USINESS Ttt1RD PARTY LING <br /> Penunec Ea'fmt�arK,vr 4 the mdculdaed APpdrao4 certify[eat 1 am the Own,,,OPwamr,or AWharrrod Attar of Ibh Ilan <br /> Ca uoes Aad/OrHouR4yCee�rtCgs aeeorialed with adso °rt1� I I�tL'e�+t an PExsaFFetS. <br /> IW'urnndua provided m this a ud Aeao Will be bed w mo a!d 1 ad toau Ide,tl tit above App die�T Annn for rLw&o. I also terdty nut nil <br /> PPlkatioa h land awl macer,Aad that all rjalagd d aWiNttu Will be performed Ili ueeordancc vtth as appanble SaN JOAQUIN oantY <br /> aypdards and STATE aed/or FTDEItAI.Lein and ItceWadWn, At lac mden aW owwerr Ordlaance COdn and/or <br /> wy apd as rnWta and oavvooOwnfal aaataemAt informAtim W SAN JOA UIN COUNTY me,W aaeat or the PmportY Iocand at the above to ffii /tile I herrby aefaoria,rhe NnOe of <br /> imvldad to me W my rtprcteomdve, Q ENYDtONM&iTAL RPA r.TN DEPARTMENT as tom as it h aed W the tame dame it la <br /> APPLICANT i PLEASE PRINT <br /> =NATO <br /> DRIVER'S LICENSE# - <br /> (aWIOCOH'REWm®t <br /> A ' <br />