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03/27/2003 07:47 916-786-0366 LFR PAGE 02/03
<br /> , 03/21/2003 11:51 4640 ENVIRONMENTALOALTH PAGE 03
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<br /> DATE MASTER FILE RECORD INFORMATION FOR1't (EH ee tn(Ranas°da:tTrar>
<br /> UNIT IV
<br /> OVINER FILE
<br /> Cod!_PLE_TETH8FOLLOW)NGBU$INESSOWNER &FORMAT/ON, ChE2A'1FGVMER=RMNr[roxptcwr gNQ 71
<br /> OWNER NArE -. �-.�___-- PHONE
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<br /> 4dac...__—m._.....___ ' IIP
<br /> 91191NEss NAME(if 471erenfAfva Ovarnr Name)
<br /> �./''/Q JI /'`,. / ,�L L>•`�)J �/ (/1{f✓�])�IC/i�//Jr rl Gl\� l,+y i SOC$Ecf TAY lD ft
<br /> I I t)Wr1ERWWE'AGtRE43 `VO� L.fif Ui 11 ���/{Inlay �V/'^•.'1 /00
<br /> VVV-�j DRIVER'S L//CIlEx3EM y�
<br /> Q!y Gf i'1i�+Pi 17 5 ' STAT$ C1T ZIP 95 741j
<br /> QYMER MNUNGAODRESG (R'alFFERfN7'IIeaR Q^^µTrargdyreas) Attandem or Care of (op&orwy) '
<br /> /i MpTng Address qky ��yrlyl'. A.a/,a state - ZIP .
<br /> fCaRPaR°TIOM hltlulGUALCI tAMMER3HIP0 LOCALAGENCvO COUNTYAGENCY❑ STATE AGENCY❑ rEO AGttN"Q OTN6R0
<br /> FACILITY FILE
<br /> rE, �:Se R , s �. . i $ 4A rt T �
<br /> G0MPLE7'ETHEP0LL0W/NG BUSINESS /FACILITY I SITE INAORRIgr)ON
<br /> b this a NM Rtlaineam LG°ATION not previously regulated by rt,EnVIRO,dWNTAL HEALTH OM310H 7 YES 0 No 13
<br /> Is this an EXISTING Business LOCATION ttutd NEW TYPE of regulated 6u3iness? YES 4 No 0
<br /> &/SINCLGFAGILITYlSITE NAME
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<br /> $ITE AttM1E3$ sumHOf y BusluE'SS PHONE
<br /> CITY ( $TATE ZAP
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<br /> Mailing Address tYalFF@RfNTylanr FAmbTyAddp&a& Athnntiont or Cafe Of(opffartaf)
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<br /> Marling Addrasa City g STATE 7JP
<br /> �gl ^I3S`„g�ry t�.:'�''iani��9 T�.n �e�dill.n"»T S � y '�; 2i4i§aa a"ySi 7'7d 'S•'"V '�e a 7 ,�'�ry„ 'Y%�}AA'.•.axe q� i �IaP I"'.,,.
<br /> r THIRD PARTY 13ILLING INFORMATION: Complete if Billing Fahy &difi'brent f/am8usiaess Owner IdentH9edabove.
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<br /> Elusim 33 NAMC Atteahl
<br /> on:CrCare Of oruf)•
<br /> Nlnifntg Address _ r BVD DWG I j/ y(,C.T ; - /oar PHONE �j/V `�✓ G/
<br /> crrr �Yher yVi IIP. STA EC� zip
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<br /> pl(pr(,q 'Forfees and Charges OWNER FACILITY/BUSINFSS TWRO PMYY BNJNG
<br /> Btyyrvr ixaCoatruANC1 AcmwLg Amt I,the andpaiped AppliCwaL eeedfy that I am the O. ..Ope'erar,ordtdhor•„ed.lgme of the Rmivess,and I aclaomledpe that as
<br /> P=t. F�'II, PBNAtnas, EMMACPMM CtMMV and/or XornV C LGR saadxted hdth th4 operation mill be billed to me at the address Idandfled above as the AQX
<br /> dBoAg for this Site I alto WM!fy that 211 Information pmv ded on IhN application G true mad emTeatl pad that at mplatcd ani-Mon will he perfmmad ht acoerdanty with all
<br /> mpplienble S,%NJoAQntN Cote i?v Ordipmpae Codes and1w Standorda and STATIC and/or FrDr,"L 1-1a2 mad Rcgulm[kna, AT the undentymed aYmen opentto.,er agent efthn property
<br /> ha2pl at the above faatiyhite address, I hereby tackorixe the relearn of any and dh mash mad m-Amntnental nz{ mcmt infra dam tm SAI'f dOAQUIM COUNTY
<br /> 6NVM0LV% MAL HEALTH DIVISION me sone as it is nailmbh And Int the vette lima it Is provided to me or my representative.
<br /> PLEASE PRINT
<br /> APPLICANrN,AME J.aE�ISeR'r SICNATtJRE
<br /> TITLE fKulvr MKrvFT 9g1•YGfiSk•16 EN
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