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-1-27-1999 d: 1 6PH FROt I P. d o <br /> DATEcc �� GREEN FORM <br /> j- 99 MASTER FILE RECORD INFORMATION MFR <br /> ,a,--42Eo I1.R_aa rp,t END e__O-#L UNIT IV <br /> D(D 0066:57 OWNER FILE <br /> COMPLETLc'T7•IEFOLLOW/NGPROPERTY OWNER /NFORMAWN: CHecxIF OWNER CURftEvrLr0'vFa6wjTHEH0 <br /> OWTY <br /> NER NAME 9C"V VCI. ' �I S OPV PHONE <br /> � aerr MI /JC�IN(J / <br /> SUSINE33 NAME + SOC SEC f TAX ID X <br /> Val�� o o la �- <br /> Owner�Hoo/me Address; �J � f, DRIVER'S LICENSE X �/u]�/L1�/•/ I <br /> City Rl e ucv—. — 9 STATE CA Zip <br /> O.M—N Al"A6ArMs <br /> Mailing Address City „ r State (1 Zip <br /> CORPORATION INDIVIDUAL O PARTNERSHIP Q <br /> _ � FED AcENGr p OTHER D <br /> 61 C) "" << FACILITY FILE <br /> '"FM MT, 111111-1111F.1.112MIXITT, uNT tb if` .W. <br /> CompiETETHEFOLLOW/NG BUSINESS I FACILITY I SITE/NFOttsmT/ON" <br /> Is this a NEW Buglness LOCA'now not previously regulated by the ENVIRONMENTAL HEALTH DIV1910H? YES NO <br /> Is this an ExlsnNe Bushless LOCATION but a NEw TYPE of regulated Su3ine6s? YF.Sp No <br /> 8uNNE3s/FAciuTYtSITE NAME <br /> 1 <br /> SITE aDINtEss rY) t7 EB 0 2 i9 ,tTFX t3uslNFss PHONE <br /> CITY ZIP <br /> n � <br /> PERP!i1T / SLR <br /> truer r�-f�a.'.f��j-n^..r ^•—'-- �.I •,M.+ <br /> 'BOA �Q.R, •... � ' <br /> _ — 11 <br /> Mailing Address ifVIFFERENTfrarrr FacififyAddressAttention:or Cue Of(aptional) / <br /> In �1 6ccw I' ve '(f)j- lt. ac /-ivtd <br /> Mailing Address City m P, / STA ZIP �v <br /> - <br /> TmRD PARTY BIutNG INFO: Completed Billing Party is different from Property Owner or Facility Operator identlfiedabove. <br /> BUSINEss NAMEen+�Oxl <br /> Attention:or Care Of ( onW) <br /> Mailing Addressn t PRONE <br /> Q I v� i/ Gb 3 <br /> CITY �o r / /� <br /> < Cl OYI.Q�t �7 O STATE (��/ 2tp <br /> 9QGS2LldQ�VBEss for fees and charges - •^ """'mac" THIRD PARTY BILLING <br /> KILLING AND CON►LUNCE ACI,' O1 NLEDCMFNT: 1.the uudemiAned 1pplicaat,Certify that I am the Owner,Operator,or Aulhorl�ed.agent of tbix St44rlc'Sa.rod 1 acknowledge that AU <br /> VF.RNT Frr_e,Pe.+.lenv_�,I vFVRC6,v6r'rCtt rRGt•J and/or Nt1C'RI.I'C114RCESV associated with this operrtioa.;U be billed to roc at the address idcntifkd above a+the A(.,(r,t,,vr141)1'ery <br /> for this ute. I shm certify that all information provided on this epplicAtion is true and correct;and that all reZulated activities will be perforrntsl in rccurdancc with all applicable$4,y <br /> )OaQVLN Cot YrY ONinancc Coda and/or Standards and Si A M.and/or Frur-xAL L.rws and Regulrtlosm As the uwkrsigoed owner,operator,or at of the property located at the <br /> above facilitynite rddrvt, I hereby authorize the release of any nod all resits and evvironrrnntAl asacmarrrenr Inforttration to SA.N JO. IN ")t;NIY FNVIRON.v1ENT.1I. <br /> ItHALTH DIVISION as soon as It h Available And nt the Same time it u provided to me or my representative. <br /> PLEASE PRINT.4 <br /> APPLICANT NAME Cla7Sd ` SIGNATURE <br /> T(TLE DRIVER'S LICENSE Y <br /> U ��V• %')4't <br /> @'r- '�"/' 't -Accountin OfIfCA.prooess Corn Q <br /> 1 - <br />