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E1005 09:41 ?094683 END _ PAGE 04 <br /> �'1„ <br /> Dep Bat <br /> �[ I <br /> GREEN,. <br /> M <br /> DATE z' �� MASTER FILE RECORD INFQRMATION "MMU"' <br /> try UNIT IV <br /> OWNER FILE &ick-4:duf!lQ RC'URREAR7.rPN.9YLffwrxEHO <br /> COMPLETE n E FOLLOWING P mpERYY OW ER rNFO)?AfAPHONE <br /> PROPERTYOWNER <br /> NAME OL- <br /> A& fA9t <br /> h� <br /> b :rr k.. r...m <br /> �. �i <br /> B457RLE'+E N+ <br /> VL L D t 'V1 <br /> _ WD w Ut✓L !/Li jr 'S LICENSE# <br /> towner me Address i '7; % ' �� <br /> ��f $TATE ZIP 0/f%.7 <br /> .7 c <br /> cin C i <br /> owner r4niGoa Address <br /> Slate rlp <br /> Mailing Add1 ess dty <br /> TY�no nurnt SNR+ FM Azwwy Q riruos 1_I <br /> f nowwa•rrnN Tu rnrolaf ❑ PnwTMcecusen <br /> Iry pal 0 <br /> Cg A= ME UFAMAZ <br /> ::Tlly� <br /> YES ❑ No ❑ <br /> T.5this a NEW RuSiness LOCATYaN nOt Previausly reguJ3ted by the ENVIRONMENTAL HEALTH DEPARTMEMT? YFS ❑ No ❑ <br /> TS tris an Efasrt+t�Business LocAT%aN bL t a New T n of regufa6ed Business <br /> BUSIM SIFAC M-TT/SrIll <br /> /A L- <br /> t Y U GLC Surm# sustw�9 PHONE <br /> SMAODMSS 2.2 /V• K Zp�_ 3 -`/g9( <br /> Z'p <br /> Cxry FSU C� � 2-2 <br /> .. '.�. <br /> _..-._. Atte.-. .. .,-n-,...... .. ..... <br /> ' $irPstRll►SQR.J'}75�R[Cr �ITJ <br /> - <br /> �.�.I_..._...,„,....,.,.. .........: ...J..,, _,, W.....„_ ,... ution:or Care Of(opbona!) <br /> Mailing Address JM-FERUXr Fad"beAddrfe <br /> STATE ztp <br /> Mailing AddreSS City <br /> 77, <br /> �i,' <br /> szccoei;'�,t : ':�i;';�' ': - dwn�r arFacility•dperator1)dt?/)7�ltdVB. <br /> THIRD PARTY BILLING INFO: COMPleteif Billing Party rsGif ta'!rJ`fromProAe Y AtMn&n:OrCareOf (60088/) <br /> SUMMM NAME <br /> PHONE <br /> Mailing Address <br /> STATE ZIP <br /> 411'y <br /> er�nrr Enno4W for fees and charges OWNER <br /> FAClLITYIt USINISS TICRI5 PARTY BILUNG <br /> �._gr ryNCE r wNh WY An(niRNT; ].tbC unders�:ned �pPlt'°" tertity(58[19Rt the +k+,OpdwlO�•Or t+,diun-ed !!t[Of tifJS Btsslncas,and I aclt tovsledge that allCertify that <br /> ration will lx blllcd to me the address Identifed abate as the Annr— r'I°T Cor tSJs <br /> site, 1 also eSII <br /> Cod 'tbar <br /> PFVALREt,ENP6RCFMENr CNARCBS anfUOr f;(O(IR4Y�t/ARCKS-r940CiatL'd wltb tlmf dIK �yttl]x erTOrrffed iA a4cardnace with all appJieaSJs$aN JOk4}tT`I ColrwrY <br /> ordinance Codes ar1NOr <br /> »lormatioo provideu an thls appllcatiom Is true sod errrrecr,and thvt al[regmatcd activltics p rtv looted at the alw+e faci]itylsite ad'rlress,F hcrcby authorize the release of <br /> Standards and STntt atxUor FEDER 1L Laws and Re2dations• the anaenJgncd owner,aperntar,pr agent 6f the pTope <br /> id at the Sam time It is <br /> any and all results and environmental assessnI inrormsOn <br /> to SAN IO�tQRi>tL h,Tr <br /> ' HeAL7F1'DEY,3RT'biEyT as s�as i#Js avaltable a <br /> provided tome or my representative. <br /> P szcyn�G / <br /> APPLICANT NAME <br /> J u1 -IDRIVBR'S LX # <br /> TMEPY UlJ r l l ` I'M40TOCO - <br /> ..;M. iM.wY1.w11�.Y1ri"•'r•!-T�"r-.+SI C0� MT•�.•� '���•'r <br /> PiO g]I "fit=c �' DBtO -' :u•J.- — °a <br /> 1.1 ve <br /> 11 r6 0 <br />