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Jul - 22 , 2003 9 : 04AM CONDOR EARTH TECHNOLOGIES No •4317 P. )/I <br /> ffffiKffi= r' ,. " 1`F111 n. ,yr <br /> GREEN FORM <br /> DATE - MASTER FILE RECORD INFORMATION "MFR" <br /> _ o - UNIT IV <br /> OWNER FILE <br /> COMPLFTETIfFFOLLOWINGPROPER OWNE INFORMATION: deerry OWNrR CNAteErvrFrtwRA,F n EHD <br /> PROPERTY OWNER PHONE <br /> NAME <br /> F',et MI <br /> BusINEs HANE Crxli't'cYrti10. �{7I��2 CUnivar ti �SIo/TAX To <br /> Owner Home Address; DA"It s LttNee it <br /> city �TA'� c A IIP 9 08 o 2- <br /> 0.. <br /> Owner nellhp addles <br /> Mailing Address City �r ggte zip <br /> MaonopryrN`I Iunvmu., DAninYvcM,e 1,1 Gcn Ancwrvi J rnucn <br /> - NI , <br /> FIN NMI gp, <br /> , <br /> y_ <br /> TNFoRmAum <br /> Is this a NEW Business L=noN not preuiuusly regulated by the ENVIRONmisfrx HEALYN DEPARTMENT? Yrs ❑ No ❑ <br /> IS this an EQSfING Business LOCATION but a New TYPE Of rlegt Whit Busltxss I Yrs ❑ No <br /> Boe[nEsa/FAaurr/SxtE NA <br /> CSU $kD�nislaLLs . 4afoe�ck�rn MiAI +-i- CCLWFV5 <br /> grEAppREtu: SVM BusINEsspnose <br /> SA-Mc LTo vt CA nIS Z0 2 <br /> aY A' WINE M, <br /> 1011 <br /> �� <br /> Mailing Address ifDIFFEREATfinm fbaW,Eddress Attention:or Care Of(0pU0naQ <br /> Mulling Address city STATE ZIP <br /> THIRD PARTY BILLING INFOi CDmp/eteYBilling Party is dflferent from Property Owner or Facility Operatoridentified above. <br /> SUSINES NAME }� y, Attention:wCare of (ORO'defel/ <br /> 5toc.IL;kDn hi 'xD� elnool LJf$ iCI �aeili{ia� f�a„N7 grEvve jvay.k4s:aLd <br /> Mailing Address 19144 ,EI 'QivLe�l iv PHONE loot- 9SS- -*ALo.x+.2 'H! <br /> COY S Eos lam{otn ”"ef4 IIP�I5zo S-zs s I <br /> d��nnata•ennncee for fees and charges OWNER FACIUW18USINESS THIRD PARTY BILLING <br /> Rn�run.Nn CnHnleur..Arv�nwt:nr.Mrn.; I,the underal=sed Applicang certify thus I am the rO, ,onmlor,ard1utharipcd Agetdofthis Business,and I acknowledge thataU PERAUT PEss, <br /> PMALTIM,ENfORCEMENTCIURGES and/or IIOUALYOrARGW asrodsted with this operation will be billed h me at the address identified above as the d r�PPEENs for this site, I also certify that <br /> all information provided on this application is true and wrrect and that All regulated activltlea will N performed In aemrdavice«stn au aMulca JOA ON Cotmn Ordinance Code and/or <br /> Standnrds and Sian and/or FXDEAL Laws and Rcyuktioos. As the undersigned owner,operator,or agent of the property located at the above d s, e u e the release of <br /> any and all result,anti environmental asssnmenl information to SAN JOAQUIN COUNTY ENYM N1MENTAL HEALTH DEPARTME a �i same time it Is <br /> provided,,,me or my repre#va[iye. �� <br /> 1 PLEASE PRINT <br /> APPLICANT NAME SINE L—j�/P� IQ��I��is SIGNATU `—I q <br /> TITLE FAG"Lt LE P6147Jn C.'p, oHOTOOW REOUI�l) tj / 1 I <br /> 1 . 'wc - _ <br /> 3L' <br />