Laserfiche WebLink
FPU f i 3480b2l t'.ulz� <br /> BATFGREEN FORM <br /> /0.x•7'00 MA--,TER FILE RECORD INFORMATION MFR" <br /> .ih1AD..ED AK4�f1iB.EtLR r ni r ' `: <br /> OWNER FILE <br /> :OMPLETE TNEfPLLOW/NGPROPERTY OWNER /NFORMATIONJ: CM� rF R4^(�I'y1�Ry�v� ]r� / [�MEl�q�� <br /> PROPERTY �1� /Q �I�-�� PHONE�f <br /> PERMIT / SEI1VIl�L-s��i <br /> OWNER NALtE <br /> l \V `J ,K` <br /> Fall M/ <br /> usINESS NAME � N� 3oc SEC/TAx ID# <br /> Jwner Homs Addrtss ��� TdG1z>re <br /> DRIVER 8 LICENSE lI <br /> _Icy � C/�C��C-TSV CA'Y STATE ZIV <br /> arrear Meiling AAdtaa I ,✓�.�,/� <br /> ,-tailing Addreas Cit J-- <br /> State Zip <br /> of <br /> ',ORPORATIQLA❑ INDIVIDUAL 11 PARTNERSHIP❑ PEC AG NCI' OTHER❑ <br /> FACILITY FILE <br /> •A Vt ��� r <br /> '04fPLE7FrHEF47LLOW/NG BUSINESS/FACILITY/ SITE /NFORMATloAr: <br /> s this a NEW Busine4s LOCATION not preVibuSly regulated by the ENVIRONMENTAL HEALTH DIVISION 7 YES p NO G <br /> this an ExISTING Business LOCATION but a NEw ryPP/EJ of regulated Business 7 YES ❑ No O -J <br /> '.'StNESS/FACILITY/SITENwM�EjI'��/�j�I��(I��l/c/�.•�4'y D `������ /�-K • -- -- <br /> ,,TE ADDRESS SUITE#• BUSINESS PHONE ---- <br /> ry I r/�/Ti�./ !/I'• <br /> :bA STATE � ZIP 2I <br /> Ivr <br /> i0 <br /> .frilling Address IfL*FFEREIVrfrom Fac;&tyAddress Attention: or Care Of(optional) <br /> I <br /> A:llling Address Ci STATE ZIP <br /> HIRD PAkTlf BI LING INFO: Complete it Billing Party is different from Property Owner or Facility Operator lden6ffedabove. <br /> dusiNESs NAME ;'(,� e 1 Attenti or Care Of (opfiona) <br /> c �rad�r <br /> Mailing Address <br /> 7u- <br /> � /uQ-- /[-e �5;V — <br /> �:IIY STATE / ?/^/-1' �QQ� <br /> ZIPrc'�7/ <br /> 4qq;_qKTAp BAzg for feesi and charges OWNER FACILITY/BUSINESS THIRD PARTY BILLING <br /> !ILINC AND Co,-IPLtAN�ACKNDWLED(aIFMT; I,the undersigned ApplicAut,certify that I am the Owner,Operator,ur,Authort:ed. Is FF7 <br /> and 1 ae:ILlowlcdge that oil <br /> h+Ila fEfsS,PTiNdI,7tEi',EN'fYJRCEM£NT rwARGL'S and/or HejuRLYCN,oGEl'ossocistrd with this vper%tion will be billed to file at the address identified xbove as Me gCC:VG-irT AI)nJ:Y_S1 <br /> -: this site. I also cerci that all information provided on this application is true and corrreh and lhut all regulated activities will be performed io accordance with all applicable SsN <br /> ,scams CouNTY Ordln ce Codec undlor Standards and STATE and/or Ftuctut,Laws and Regulationq. As the undersigned owner,operator,or agent of the property located at thr <br /> o facility/site rddl,<Sa, [ hereby authorim the releace of any and all results and envirnnmenral asyGgeement information to .'AIT Jt)AQL:LV COUNTY ENVIRON1sfE,,VTA1. <br /> . a I XK DIVISIONi as loon as it is rvailuble and at the same time itis provided to me or MY tcpr>•sentativa r <br /> �/� <br /> PLEASE PRINT <br /> APPLICANT NAME �I S SIGNATU <br /> TITLE R' <br /> �,� ,// DRIVES LICENSE# ,Q <br /> C// <br />