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114,14/20M 1/:Ib 11 y4b133433 FfFTH FLOM PAGE 03
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<br /> ...�,;.,:,,. MASTER FILE RECORD INFOR _ •, �. ,r
<br /> BATE Ys', r.:�t : .,....�.,: UNIT IV
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<br /> oWNER FILE c90pC191�
<br /> ox IF OWNER CURREArT;YOArFILEuur7rrEH0
<br /> :OMPLErETHEFOLLOWING BUSINESS OWNER INFORMAT10N_-J�� - .� __.,, _._- -------- _..--._...
<br /> CC PWONE
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<br /> OWNER NAME 1---. ..Yil. _ rrr
<br /> ............._ .. .__. .......—_.F... '- ' --.....--.. ........_�.... .._ ...r-- Soc SEc i TAX 1 D C
<br /> SUStNEss NAME(tf different born Owner Name)
<br /> DRIVER'S LICENSE i
<br /> OWNER HOME AOORES$ ) sY 2001nliml
<br /> s SATE//* ZJv.
<br /> Atbantitxe orC*M ofOWNER MAIUNCADDRESS (if01FfERENTfrom OwrrerAt d—roState yMailing Address City
<br /> CORPORATION❑ iNDIVIDUAI PARTNE"HIP❑ LOCM.AGENCY❑ COIx'tTY A6ENCY❑ STATE AGl7et.'Y❑ FED O
<br /> FACILITY FIVE
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<br /> CoMF1-E7E7'HEF01.40w1NG BUSINESS 1 FACILITY/ SITE INFORMATION: Yes ❑ NO O
<br /> Is tills a NEW 8usina"LOCATION not preViOU3fy regulatAd by this ENVIRONMENTAL HEALTH DIVISION
<br /> Ytes ❑ NO ❑
<br /> Is thi*an E)aSTING Bttaineas LOCAYION but a NEW TrPE taf reggulaled Business 1
<br /> BUstNEss/FACIUTY/SITE NAIVE
<br /> {� f� SURE i BUSINESS PHONE
<br /> SITEAoCRE33 nG1 JXl y -(f
<br /> ' STATE ZIP
<br /> CITY :.+.• s :; :)2<:�'• » ' ^;: io,`::ff s<,y.,.F r: SF$ '•n k\Y°.••:4.:';
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<br /> > Attention:or Care Of(OPNO aq
<br /> Mailing Address sYD/FFERENTfrorrJFacility Address
<br /> STATE ZIP
<br /> Mailing Address City
<br /> ..;.kble
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<br /> THIRD PARTY BILLING INrORMA-now Complete if 8illing Party is different from business Owner Identified above^
<br /> ..__._.........._—........._�__ --
<br /> ---_.... -_..........._............._. .. —........__.
<br /> -. ; AttenMtion_arCare Of (optitarryl
<br /> Bus1NESs NAME
<br /> PHONE
<br /> Mailing Address
<br /> STATEy 4P
<br /> CITv G C
<br /> A�gQQg5 for fees and charges OWNER
<br /> FactLrrfl6uslNess THIRD PARTY BuiN��
<br /> ledge
<br /> BIL Ivt•.W CDMPt I CE. Ic4O%7 fin<,+kNT; I,the undersigned Applicant,certify that I am the 0+ zr,Operazor,orelt�rt�ori:ed A�aK of this Business and C aclaas the-A that
<br /> pr&vjr Fgg.S PENAL= ENFORCf•NENr wfARCEs and/or hrOURLY Cts+RCss assoeiatcd .With this operation orifi be billed to me at the address Identified above u the.1[Cot
<br /> 1DDREG for this site. 1 aLsO certify that all information provided on [his application u true acorrect: and correacrd that 30 regulated activities will be performed in accordance-ith
<br /> applicable S)N JoAQUCI ColrtTl[Ordinance Codes andfor Standards and STATE And] FEDEtLa1 Laws and Regulations ,as the undersigned owner,operator,eK aunt of the pre
<br /> located at the above facility/site address. I hcrebY authorize the release of env and all results and environmental asses sment information to S.a2! •fOAQLIY COU,
<br /> ENV'IROKMEt`IT iL HFALTH DIVISION as soon Its it is available and at the same time it is provided to me or my mprmentativc-
<br /> PLEASE PRINT
<br /> �— SIGNATU
<br /> APPLICANT NAME
<br /> DRlvrcft S LICENSE x
<br /> 7L//rf 7 �
<br /> 71TLELl- l� t sY i :a •4 aRA
<br /> ' !<:,4
<br /> ;A�t}praveatc�i�
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