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<br /> 7. o `cur Elb'ii:t+:-rxa 1' H�aft�r Services En�ironplenta, �ealtt* f>ivision _
<br /> j, __. . r .____ ___ .GREEN FORM
<br /> DATE MAST ER FILE RECORD INFORMATION "MFR"
<br /> SMAoFo ARr,AAFVREHDVC
<br /> SENL• t'. UNIT IV
<br /> �l f
<br /> OWNER FILE
<br /> Co.4fPcETE mEFoccownvaPROPERTY OWNER INFORMA)70N: CHOCKIF OWNER GG'RREMLYONF/LSL%ITHEHD
<br /> P*CPFAYy `n'n A .�I ( � /�/' PHrONE (///y //` U
<br /> OWNER NAME ('.P•�cl� �A-�Ie�U ��.� l�T' \i�. l%lel � � ( ESN l�` I �V I,� q v
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<br /> 8U91NErs NAME SOC Sa:C 1 lax ID K
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<br /> Owner Horne Address DRIVER'SLICENsEx
<br /> City STATE ZP
<br /> Own•rr"'log AdEross \}l �'
<br /> I i 0.35 W- •; ;\JI �1 t^c c� 'n� �t �?
<br /> Mliiling Address City ` �- �
<br /> State zip �Z
<br /> CORKMATIOII INOIVICUAL PARTMERSHIP FED AGENCYU-11 OTHER
<br /> FACILITY FILA
<br /> � :' �t 1"Sr m�..•a,q( .rc•I r�_•,-u•'yywi'.a+ww.I Zn P5n+1'! .?.r.�-�.w:,..•. ..4��y 3 N,
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<br /> COMPLETETXEFOLL owma BUSINESS/FACILITY 1 SITE INFORMATION.'
<br /> Is this a NEW Business LOCATION not previously regulated by the ENWRONMENTAL HEALTH DIVISION 1 YES ❑ NO
<br /> Is this an ExiSTINO Business LocAT,ON but a NEW TYPE of regulated Bueiness YES ❑ No
<br /> BJ3tNE3a1FAGLITYISITE NAME
<br /> SITE ADDRESS (` �Q C) I r1�C� SURE 9BUSINE36 PHONE _
<br /> CRY 1 lrtl,ln S �STrTTC zIP� Z 5
<br /> _"." T� � � ,?1 J' •v ti1"i)3'..i4 r g *-+ L - 'Sei�5- ur+ "i.w.,+r i.�1�r;,r' �
<br /> [SOAti60FYSU~PERYISOR..1,.:•, lit _:... .��t:aTjOK.__.rr�.'I .,..:,_. ���..:1.... _..__t._..-.t ,.___�dC£Y'2—._ .,..... _.i._ ....... .
<br /> Maltin1g/A�ddre s IfDIFFERZAir fkom FecilltyAddress Attentiorc or Care Of(optionaf)
<br /> Mailing Addrea2 City t rt STATE zip C —]
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<br /> S1C,CoDG ` , 'APN 8 COMMENT'
<br /> THIRD PARTY BILLING INFO: Complela if Billing Party is different from Property Owner or Facility Operator identified above.
<br /> Busixess NAME ( „,- T f1 v���� .� Attention:or Care Of (optional)
<br /> Idaillnq Address +���` `�> 1�, �!
<br /> CRY I'J^, „� STATE ZIP C qvl
<br /> /JCear�vrC)14,p r(Efs1 for fees and charges OWNER FACILITY/BUSINESS THIRD PARTY BILLING
<br /> BILLTNO Ati D COMPl.L1NCE ACFCNOWLEDCNrL-4Y_ I,the unders;rAed,1.pplknnt,ecrlify that I xm the 01"'Er,OFerator,or.Iu:hmi-,•cd Alen!of thk%Rusfnm and 1 neknowIcdSt mat all
<br /> PLRartrFryl $VA/,T/ X C.fORCGNL�1 ClLIRGGS Aad or XOLrti YCH:trcces'associated with this operation wi0 be billed to me at the address IdentiLed shove as the,i-,*cy••t7ADDRE.,.y
<br /> for this site I abo certify that all infornzatlor provided on this upplicarion Is true and correct;and that ail regulated ACtiviti(s wt71 be performed in accordance with all agnilicibk&.N
<br /> JOAQCLv COUNTY Ordinance Codes andtor Standards and STATE And/or FEDEiL%L LAWS and RC,ahttions. a undersigned owner,operator.or agent of the property Ineatod nt the
<br /> ubcve fac tiO-Mly nddnn, I hereby authorize the release of any and all resutts and environmental •nt information to',LN JOAQt,IN COUNTY E.NV1R0N.MTNT,%1.
<br /> HEALTH DIVISION as soon as itis Avsiable and at the same time it is provided to me or my rapre"ats
<br /> PL9A3C PRINT \f
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<br /> APPLICANT NAM �Q �
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<br /> t� �BRIVE�CENSE#' Zl
<br /> TITLE �L�b`�11 T
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<br /> •Apprnvtadi8y ;,r�`:n: .r r :•tea �_t«t r,":r. 31i: '+Aaeiwngrrgijffio SJn �..1, _ Oale "F
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