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05-10-2-10311 01:3Cepr'1 FROM TO
<br /> DATE ` ---- der,,,„ �t7s . GREENFORM
<br /> AfAtEMS?.�,r o.x. �, litIN
<br /> N • vY Y ,a'wr,r+
<br /> PI UNIT IV
<br /> OWNER FILE
<br /> /o .- CHHc ,F OWNER Cuk"NaroNFEMrn EHD9tiPLETETHEFOLLOW/NGPROPERTYOWNER /NFOR6AO039o -
<br /> OPWRNOEPR6NHTAM'E ICHAEL yPUO�NE
<br /> xR
<br /> ,J >viess NaNE coymce - mfll ,,,r (z) $OG SEC I Tas ID
<br /> 9tf- I SIyL
<br /> caner Homo Addr068 / '1 DRIVER'SLACENSEF MpU
<br /> ti
<br /> , tfoZo �. hSrkclyC� �b t CLQ ( STATE
<br /> M etlma AOanq
<br /> ailing Addresa City State Zip
<br /> I
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<br /> )RPORATIONp< INDIVIDUAL❑ PARTNEIISNIPO
<br /> FED AGry+cTO OTHER❑
<br /> FACILITY FILE 3
<br /> ” 'T=:�r7r wo,) 7°' ix �-�Tv .w'Waiv'x4 �.-�^`�r'.�5ee± ?. vi. '",.n ;atia- v lt9p 3 + '.-: vA` 4!q•Yrrr *-, p� ..
<br /> •aPrt:ITTYDA .( :.;�.r �.,.r-z:i3'yu t ROBS' Ex ID><'�r �-3sk?75�Irt�+�`� �',y' CAUNT Dyl, 't nT ...rAy •,�{,,'�h. ..�irr�;�'k'a ". `o, .,
<br /> IMPLETETHEFOCLOW/Nc BUSINESS 1,,FACILITY I SITE/Nr0q,4fATWJV.1
<br /> this a New Business LounoN not previously regulated M the EHvIROkwatTaL Ht :r i Otvtstom? YES ❑ Now
<br /> this sn ExisTmG Suslnesa LOCAMN but a Nev TYOG of regulated business?
<br /> YES ❑ No
<br /> ISR,ESs/FACAIry1SITE Nahie
<br /> CS&AI-CR Ec)tn1PM4A17'
<br /> rE AOOREaa SLATE Buzmess P
<br /> N HONE
<br /> 4ULe/oy �M�wTdAJ KA . , (t7_01) 131- 300 _
<br /> ry S7—rJL •—/ 6/[V ' c /L STATE ZIP
<br /> knr� ���ew!h"-•
<br /> l..i r;'°y`a;a� I�CAO
<br /> :.:.e.:..a.�: .E� � �.,..Wtlt$.EYi ai,...rrI.�y�,rt'ryarsx-tlr•�»'�>.v.�:�KQ3.�'��1..0`��'�4:,�•"s�,.�ra..:.�k
<br /> Jling Address W IDIFFERENT from FaCUity AOJiass
<br /> Attention:or Cara Of(opUone/)
<br /> tiling Address Clty STATE ZIP
<br /> YfY:4+i ;6c.aFSsfA31fF �...., .,
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<br /> pit
<br /> a°�"*'^7'
<br /> IRD PARTY BILLING INFO: Complete if Silting Party is different from Property Owner orPacility Operator identiNedabove.,
<br /> BIHEss NAME AlL A SS tic/ TES /M ¢Attontloor Care Of fopGonag
<br /> tiling Address A �'O('. J!v " �`/ e 7'` t PHOH
<br /> tY PC FUc. 7 f,[ CA 'J f 03 $7ATEJ )ZIP C bVu
<br /> Ov_ryZ9.G sm for fees and charges i OWNER FActurriBUSINESS THIRD PARTY BILLING
<br /> InG Anu COntPUANO:ACIiAION'I EDfnte:NT: I.the xiufe>,igncd Applionl.eenily Ihxt i am the Ownrr,bpuamr,or Ar1/,w1yeJ.igenl of thu Ou&uu,'and 1 uckmwl Jgc Met all
<br /> r(r rk&v,pFNdLnEQ E.Y}pJeCt'AIEMGL,HGFS aad/or HovxL r CSrt 6O maweimtvd with this opcladoa will be billed to me at the mdar�identified above 1H the ALYONIAT,taUFLic
<br /> lis sum i al>o certify that all Infornwtion prpvideTl on Nis Application is tree and cmT'ce:and that all regulated acdvhle will be 1wrtonned is aceoNmam with all apldkablc SAN
<br /> ann CCuH Ordinance Codes mW/or StsndarJ3 mad SfA'M andlor Fwcii I.Lwa and IiegOlAlions. Am the uRlkrslynad owner,operator.or agml o[Ihe prolmny In<mte.l at the
<br /> U P siillyhite adJl , 1 hereby authorize the,elemtt OIf any and all real lu and cnviroawenul yss ,Relit In OMMIL1on to SAN JO.AQUIN COUNTY HNVIRONMF,NI AL
<br /> LTII DIVISION as Seo-as it is available mud at the sam<dma it is luovklcd to ovew my repreaenb<ive.
<br /> PLEASE PRINT
<br /> PLICANT NAME AlkvIA D-Luz SIGNATURE
<br /> LE fQTlEc-T GA6LOGW-, DRIVER'S UCENSEA N�U30�(S5�
<br /> IFHATnfAtry RI'M"Wnl
<br /> 1 rayN,raR Dale'Sri"riASs01, t�fnaOntm PrM.e t d d5 9? tv?a.av
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