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12/08/2000 09: 57 2094683433 FIFTH FLOOR PAGE 02 <br /> • 2094683433 <br /> + Sawc oa uiIIII County; PubliM <br /> c Health Services ' Environmental.H e,rth Division . <br /> GREEN FOR <br /> DATE MASTER FILE RECORD INFORMATION "MFR" <br /> S,,,,EHO uer aa• DWNtR IDA <br /> UNIT IV'. X04 <br /> OWNER FILE <br /> GYfFfX 1p OWNER CUxxe+ErLY0NF4e WrnfEHD• _ <br /> MPLE7E THE FOL LOWING PROPERTY OW N E R INFORMATION: I <br /> & N. f,V„' PHONE�1�—�38-�✓ 0 <br /> '.OPCN OWNER \t `Ty_.prtr/_ NfT/ <br /> NAME �'t V�(i}NtIT1J l a• <br /> FiSf MI last <br /> ^ socsEc/TAZID# <br /> IStNPSS NAME PrP tLL1 rfECllr\`�tY/7Y,"t r 1 DRNER•S U[[NSE iF <br /> Niter Home Address <br /> a OR'1 S�Are q 56 <br /> mu Malllnp lddiasl <br /> . stets w A Zip �S <br /> .ailing Address City , <br /> IPE OFO NE HIP FED AgENCY❑ OTHER❑ <br /> ORDOaarroN❑ INDNrDnAL❑ PARTNERSHtP❑ <br /> FACILITY FILE <br /> Fiauiy.ID#+ �. '. CRO55 REP ID# <br /> 7MPLET£THEFOLLOWING BUSINESS/ FACILITY/ SITE RMA 7701V.' YEs ❑ No <br /> s this a New Business Lounon not previously regulated by the ENVIRONMENTALHEtiLrN DNOaON 7 YEs ❑ NO <br /> s thlS an ElO5f1NO Business LoUno i but a NE v,sE of regulated Bsislness 4 <br /> 3USINE55/PAQIm/$IiE NAME 41, <br /> SUTEABUAInc PHONE <br /> itE Aoos 1qy <br /> 2qq <br /> t <br /> crry <br /> BOARD OF SuPERYSOR DTStRICT I. I Loc;Snom CODE I I :KEYS <br /> .. - Attention:or Care Of(optional) <br /> Met iting Address ifOIFFERENThom Fac:WtyAddme Mi. 1 <br /> 05 <br /> NOW 61 WO E STATE ht� zip <br /> Halling Address City {Lx <br /> I <br /> SIC.Cone f M a IapN# I:'1 .P r N. COMMEM:'. 9. . 5 . _` , , t :.,C E.�i,. 1 x <br /> THIRD PARTY BILLING INFO'. Complete if Billing Party is different from Property Owner txFacility Operator identified above. <br /> V ��� 1 AtteiKion:arCare Of -ru laq Z <br /> 1BU51NES NWE 4TOCUT-o_ r 1 pmvv�j� ^ IYIVG II 1 <br /> _r n N 1Ywtl//itE/.{yt NV, PHONE <br /> Mailing AddresS /v ✓ VO <br /> STA t['A IIP <br /> g�QyprTGonatss for fees and charges OWNER FACILITYISUSINESS THIRD PARTY BILLING <br /> It, <br /> s.l�'O aN rsuFi.0 s:Nnw' mrNT: I,the undersigned Applicant,cerr f,that E am<he d'wnn,Op <br /> eraror,or Authomcd Agent of this BnainL i,and I vckssoWINgn Ihat all PERM!r Fe PS, <br /> Pta'.N/lCe,EbToaeEMAVT CHnRGLS mIdlor TiOORLY CH uGES assoelased with 1h15 operation will De allied m site at the address Identified above as the ACCDUxrADDAF_(5 for This site. 1 also certify thai all <br /> 'm!ormadon Provided on this application is true and correct;and that all regulated a<tivinel win b performed in accordance with an applicable SaN JOAQUIN COVHI'Y Otd;'sor Code,sekvc of <br /> Swadards and STNS AM)or PEsmR Laws and Regola6hm. As the undanighed owner,operate,or agent of the propertyDTVIlocated at the above t it I iyhile adds*,I (be same <br /> nav and ail resuln and environmental assessment Information m SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DIVISION as soon as it Is ava/il�aDM and at the some time Iris provided m <br /> me or. rcp•aenladvc. PLEASE PRINT <br /> I ✓ <br /> '/ <br /> APPLICANT NAME SIGNATURE L AI`l/L�I 1/L/�iY <br /> i t j� ,s �y✓���/ RyN RIS UCENSEfF i e <br /> p( <br /> p /' i101000PrREQUIRE�) <br /> TITLE S Eco <br /> "untJng DRioe Piocding:fnanpleued By Date <br /> ApprtMred lsY :.- - DaOa .. '. . <br />