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!2002 X1:09 20946834 V � IF— H FLOOR rCOPY
<br /> RGE 04
<br /> 01,9 /■p1r/n1I_� tL E _
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<br /> FILE RECORD INFORMATION
<br /> NIT IV
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<br /> OWNER FILE El
<br /> OWNER Cf1RRfMLYONFI1.Ei17T/YEl'IO
<br /> :OMFLF7E7-REFQLLOW/NGBUSINESSOWNER INFORMATION: ..,,_.-__ ._......._—_ ... ^__ _. .._..._.W.._.... .....,
<br /> ....... _ ... � Y --: 73
<br /> ALI_.__...� _.._r_— PHONE n-
<br /> BLSINESS 7 Y
<br /> i 5
<br /> OWNER NAME ——
<br /> ^ .v.... .'._•• !?t....,...,- - .. ..._...........L,@51.�............... li U
<br /> -.._................._.__....__.........-......_.... _ ._-...... SOCSE0TAXID0
<br /> EUStN.ZS NAME(if dMr uog 6Vm Owner Name)
<br /> A oRtveies umNsEm
<br /> OWNER HOME AODNESS /97Lo r !r (A C«
<br /> STATE ZIP 9 S
<br /> Ow
<br /> OWNERMA.IlPub6A00AES3 (ifDJFFERFJVTfrnmO�r>eraddr )
<br /> AUention: orCara of (optior=1)
<br /> State Zip
<br /> Making Addre%s City
<br /> 0 PARTNEiSt'IIP LOCALAGENCY Q COUNTY(AGENCY O STATE Ar.ENGT❑ Fm AGENCY Q OTHER Cl
<br /> CORPORATION C1 INDIVIDUAL "
<br /> FACIL,R FILE
<br /> ,-. 't' :"s;1y'Set�?s'',Sid K� '•k .Ft3�.�"! "'� ` �`: .�..t,;...ta` ,�fo".,i '�'` y �! � � _..
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<br /> CoMpLETETHEFou.owjNG BUSINESS ! FACILITY.! 517E INFORM�TfQ1V. YES fl
<br /> 15 els a 14CW 6uain*s;;s LOCATION nOt,previously regulated by the liNWRONMEltTAL HEALT-14 OtYlslOt?7. _ �. .
<br /> Mated 6trsineas? YES � No �
<br /> Is this an EXIVING Business LOCATION t)Vt a NEw TYPE of reg -
<br /> 6[t51NESSfFAC1LIITI51TEN6bIE i,L QN L
<br /> rff SUITElI BuSINESSPHONE
<br /> SITE ADDRESS
<br /> rSTATE ZIP
<br /> CITY f {"Q C •;• sr;.�t,cx:*a'�6-k ..;, i y: :..Yw �,�« S .y
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<br /> °'`fit tlr r,i:l
<br /> 3: (+ l�a;•r, ? 4 >3�'sry ? ,: l
<br /> i Amention: or Care Of(op6orwi)
<br /> Mailing Address ifD1jePeRENTfinrn pariJilyAddress
<br /> r r� STATE ZIP
<br /> Mailing Address Cty
<br /> V a rmo.• r o. F
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<br /> A- 19.1,111
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<br /> INFORMA71dN: Complete if Billing Party !s rent from Busi[Iess Owner Identified�bo.....••
<br /> THIRD PARTY BILLING _ ---. ...... _ . - •— - -_ _...
<br /> TAdentkm:or-Care Of (OP60 00 i
<br /> BUSINESS NAME f
<br /> CJv�
<br /> -
<br /> Malling Address v
<br /> Cti'YCLLW[C0V' STATt /1 i 7JP�C
<br /> �Cy-ouHTAJIDBE:34
<br /> USINES5 THIRD PARTY SIU AI
<br /> for fees and charges OWNER
<br /> FAcnml
<br /> mer,or Irrrhori:sd Qess and i acLvo.+ledge that all
<br /> Rrt_r[VC C aMPL1 Ac te`IO�x+f-1 b 1,the undersigned Applicant,mrdry that I am the Utividl' OPQ
<br /> PEWr FESS, pryALTTZS. ENFORCr.vzF.d C&LRCSS aadior MOURLY CKAAV s zssod2 with this op tion will be billed to me at i the addI b id
<br /> rnerrac above accordance Che�Crot+all
<br /> Ag)Rrss for this site. I also certify that 211 inrormatioo provided on this 2pplication is true and correct: mrd that all regulated acivltixs till he p�'�cd 'a of he perty
<br /> all
<br /> applicable Stty JOAQ[IL`I OGtt,iTY Ordinance Codes andior Standards and STATE and/or FEDI;.RAL Laws and F 9ulatioa As the undersigned owner,oper+tuYof agent IIfC�COVirIY
<br /> located at the 2b0re facility/site addr� I herebv authorize the rolease cf arty mm&i all results and envlrontnental 255�scmen[ iaCarmation to 5r4 Q
<br /> F,rMONML ZNT.tL�etiT,TH DIVISION as 594)"2$it is avaiiablc and at the same time it u prorided to the Dr my rapresbatative
<br /> PLEASE PRINT
<br /> SIGNATUR
<br /> APPLICANT NAME
<br /> ORIVEWS LICENSED
<br /> TITLE `
<br /> r> ,-Y` ,L t�..'�`�•�u'' .,4o-
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