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rJ7! 10/ Ltjri4 10. Uju 4UD40634J.3 � r Lr Irl rLuur-, r"HUt t7L <br /> OWN <br /> ` DDATC` GREEN FORM <br /> MASTER FILE RECOR6 INFORMATION "MFR'S <br /> UNt't' IV <br /> tt?D f a J I NER FILE <br /> COMPU7FF7NEFi?ll067NGP bPERTY OWNS IN�011MA770N; 0yA1rK7F OWNER cvmWmy0mfnr vn:<eHa <br /> 1PROPERTYOWN@t � �� �' K� <br /> NAW <br /> Busutrss usum <br /> SOC SEC/TAX ID <br /> Owner NanrrQ Address O- R'S LIC �I <br /> -- STATEC Zrp Sa <br /> 0-.airs - . <br /> Mating Addy City slabe Zip <br /> rnsenwaTrrw❑ ia�nmu u,l D�aTf.pp biro❑ FXn MSYfv❑ /7rsse❑ <br /> 92° aa� <br /> Is this a MEw l31isit»s 1 oCaTion not previously MgUhftd bV t7te�At.HMTH DEPARTMENT? YES ❑ Na <br /> Is this an Damm Ru LOCATION but a Nr:W TYPE of regulated Business? YES ❑ No� <br /> / NAME S l P.L. <br /> SMAbORESS <br /> J f}(03 /V Z4t\) cJNCr/ DAJ #-- : PHWE <br /> CUTS�o C d S1rA,, 64 ZIP J za G <br /> im WV <br /> Mailing Address/fDn7mz 7VrfiTlm Facyltr Addrm Att tttWm:yr Cdfe Of(, <br /> R <br /> Marling Andress City <br /> W <br /> x <br /> rMIRD PARTY HILUM®INFO. Complete if Billing Party tsdferentflrxll P <br /> MXMESSNA,w� rope1tyowner orFacifityOperator �above. <br /> Atb-tion:orCareof° taptivaa0�/^ <br /> Mailing Address r 5 <br /> Cn <br /> ALcX9AYrwn0ar-,qW for fee's and charges OWNER FActurY/EUSINESS fR0 PARTY BEIIING X <br /> 1, nadcriigncd Apptirrat;ratify that 1 sm the Ow ,oyararorr or Ataharza Agem or th4 Bus 1,and t, 0rjcdge that an pERs�zFL <br /> 'es�vwcnr�F-wvkc&vr,vTOiA =wWOr HOVRLY C�IAaGPS amocUted site this operadon wall Dt bn7lcd to tae at[he add EdnlnIIed ADov<ac the�ZB1)21p, tar thio site. [t artily nut SE <br /> ofbmud.h provided on nnx app&atSoD is true and comet•,and that all trgtdated activities will be perforhncd in aeeordatce with aD applicable SAN JOAQUrN COUN-1Y Ordiaanm Codes aud/or <br /> AmidimN and STATE and/or Fvm4RAL Larm and Regndasom. As the undercigntd owner.operator,or agtot or the propffly located nt the above f•�ciptylrite address,r beraby autberia the rdeme or <br /> "Y and all results and Cnvfr00Mentll assessment iarormntion to SAN JOAQUIN COUNTY ENVIRONMFANTAL IIEAUTA DE AYLTMENT as soon u it is avaabk and at the same time it is <br /> rvvided to me or nky rgwmntat vt. <br /> PtE+SE PRIIV rI <br /> APF'LIG4NT NAME _ SIGNATURE <br /> TITLE <br /> 'r ,F. •r_..- '!'�R'r, .six,++ ..p"Gr-gra--r-r-� .r •nr� <br />