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11-05-1998 03:08HN FROM TO 19255069260 P..02 <br /> Y '1" tC7 x"18 y,� <br /> ,.I_ d6R ro.;• i7�'a..J."S{ w,i 'ilar,h,Aw....�..;. �. J., 'g i...�r.,..l~•. ,.-�'P..... , + <br /> GREEN FOR <br /> =6DATEj -`)g MASTER FILE RECORD INFORMATION `.`MFR" <br />�I <br /> UNIT IV <br /> OWNER FILE <br /> COMP,tEIE7MHEF LLOWINdPR0PI;RTY OWNER /NFORMA7ION.- Cmrcx1F OWNER CURRFNrLYoNF1LFwrTNEHD <br /> PRDOERTY ' PHONE (/ �] -117 <br /> J `� <br /> OWNER NAME II e r-1>1 -'C_- FO V 7LC. Ci 2 S�.CJ/ J I 1 r <br /> FYtl Arf ae <br /> BUSINC59 NAME! SOC SEC f TAX[DO <br /> 1} roeiY,\) <br /> Owner Home Address DRIVER'S LICENSF A <br /> - I <br /> Clty I STATE 21P <br /> Dwnee Metgnp hddrawe <br /> 3 / f 7 1 1'� <br /> i U .S7Lr r P A/D S o 1 <br /> Melling Addram�City' State <br /> C� <br /> -CMPORATIQNtL I IND1VIt1UAt 0_ PARTNERSHIP❑ ..--. .•,••��-,• FED AGENCY 0 OTHER❑ <br /> FACILITY FILE <br /> COMPLETE EF 'LLOWiN6 BUSINESS I FACILITY SITE INFORMAr10N.' <br /> Is alfa a NEW eualne93 LDCAmN.not prmvlously regulated by the ENVIRONMENTAL.HEALTH DIVISION? YES 0 No <br /> I <br /> Is Ihla on Exr8nN4 Buf{ness LOCATION but a NEW TYPE of regulated Business 7 YES Q No i <br /> 6U9INEsv1rACILf1Yl$ITE NAME <br /> 917E AnDREss T / _1_ SUITE 8 13USINESS PHONE <br /> Cm 61 L $TAT�-M1 zip J <br /> ...._. _ _..f..�,., .I . .J ,t,�.': 4'„�..M �r.,�;rtr, 6I.�h,r�4.�w '. .•,I'i, C„!1k�,k5:, '°,t��l,. .R.11. d. 4 .:li <br /> Mailing Addrean 1fDkFtRENTframFarcltoAddress Attention:or Care Of 2�6 (optional <br /> �Acrlre' / DL'!C� <br /> Mailing Addre9g City Jl STATE ZIP II ff <br /> f <br /> X <br /> THIRD PARTVi BIL ZING INFO; Complete If Billing Party Is dlfferent from Proporty Owner orFaciiity Operator tdentmedabove. <br /> 9val►,sse NAME I J t� AttsnHon:'orCare Of (optional) 1� <br /> Halling Addrvab <br /> Ctry STATE ZIP <br /> I L-l c,rn c l <br /> .r <br /> for foes and charges OWNER FACILtrr18tis1lurss = T141RD PARTY BILLING <br /> tilLklN AND COM rtkApit I.ACKNOWLEDGMENT:'T,the undersigned Applicant.eerliry that I am the Oamtr.Opomfor,or A1d/hortzrd Agree of lhi`c Dusincss,and 1 atknom ledge Thal nil <br /> P£R,Sf FjrEv,P£NAt.rm s. FARaME TClfaRCECandlorHOURII'CNARFss mm 01 ted Wit this ofiirmllon Ivill be billed 10 me at the addrest idenUfitd Above ns Ihe.tQCBUP7ADpRMT <br /> ror Ihta site. 1 also[ertlry that All Inrarrnnllon provided on th,s nppRrnlion U true grid correct-,and that alt regalalcd ncllrltics will be pevforwod in accordance wilh all Applrcabic SAN' <br /> JOAQUIN COUNTY Ordirinnice Cedes and/or StAndards and STATE nndlor F'etiaaAe.Deva And Rcgufallons. As the undersle.hed o+rnes,operater.or ngcet ur the property}peeled at the <br /> nbove fncllltylthe nddress't I ht"by Aothorize the release or any and all results and envtronmentat gssGwsrneat lnrormntlon to SAN JOAQUIN COUNTY ENVIRONNIMIAL <br /> HEALTH DIVISION as Zw on as It Is arAllAblc and al the some time It Is provided to moor my represenkl;ve <br /> f PLUAsE Ppoff _ <br /> APPLICANT NAME I /' ems` SIGNATURE <br /> TITt.f AC.�QTY.{.t �G / b : l DRIVER'$LICEN LILTS ct q a <br /> 1 <br /> 1 <br /> TOTAL P.02 <br />