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0`7-10-2001 01.3EF11 FF`ON Ti-i i530=-I1 F i}._ <br /> SATE MAS R FILE RECORD INFORMATION "MFR" GREEN FORM <br /> 4' <br /> !f. Dort iFAtfNO lar Ow• � •�E�t }�': .^Y <br /> n. t �, UNIT IV <br /> OWNER PILE <br /> 9MPLETE7HEFOLLOWVVGPROPERIYOWNER INFORAfAnow CeEcuv OWNER 0ua4EH7trONr1,S irnEHD <br /> pfu P"ATy <br /> Dw,6aMIME f 1I c- A EL <br /> Fir wa <br /> uswEss N.ME CO LAI <br /> r'A ' A� � �C $oc$Eo/T.ulOp <br /> lrl 9'f- 1 +2-S-7q Z_ <br /> Wner HOMOAddress <br /> (S I■� � TQ'1, ,�/� R{/I, / (� DgIVEIYy UACEN5E4 MOT�L(, \ , <br /> ity LNTO 4 • rl� N ra'VV 1 'f+ , tc)h 1 <br /> -T TE <br /> �l \ Z �J �T(.] <br /> •nor Mailing Adored* <br /> ailL]9 Address City <br /> State Zip <br /> )RVORATIOH�< INDIWDUAI0 PARiNERSNIP0 FED AGCNCT❑ OTHEit❑ <br /> FACILITY FILE <br /> `:':GT=ssk+^'r wwr'�i`.s��*aa{t-M.sbi: 'CnOP� �IDS.,.. .... �r :i'3`,I,A.k✓02 <br /> It <br /> IMF4E7ETHEFOLLOWING BUSINESS I FACILITY I SITE&FOau4nom, <br /> this a NEw Business L.ounoN not previously regulated by the ENMROtu"NTAt.HEALTH Envision? Yes cl /4ox <br /> IN--an FX15nnG Business Looanom but a NEYi TYPE of regulated Business? YES ❑ No <br /> h <br /> IswEss/FAauTY1SITE NAME <br /> CJYIvCQ �pvIIPM�p- CLQ <br /> fE ADOMiSSty SUITE# BUSINESS PHONE <br /> LOLO M�w72W �� , LLi) 111 300 <br /> IY cSTJLI- 1 LVL1 I c,A STATE Zip 9SLJS _. <br /> kd <br /> dung Address if p/FFERENT tion FecOiry AOOress Attention:or Care Of(opNonaQ <br /> Wing Address City STATE Zip <br /> IRD PARTY BILLING INFO: COMPlete if Billing Patty isOi rOrent from Property Owner or Facility Operator rden1iA6d above. <br /> ,siNEss NAME r1 2Tr— Attontlorc OrCare Of (option,/) <br /> SSUct TiEtS //VC . <br /> d1ing Addrels�=-pP.. C). at))( <br /> J(v /��L1 C� c '` PHON f(•-1� <br /> !"El t.0 ] /rX, L•J•T I.J To.I STATE J ZIP <br /> 1'.t?UIyL�,QIjgESB for fees and charges i OWNER FACIU YiBUSINESS THIRD PARTY BILLING <br /> INC AND COMPIIsNrl.AEKN Wi EDC.MI.NT. i•the undersigned Appiiemm,ecniy that l and the owner.U aur.Or. ARMw1TeJ+1, <br /> I(T FEB#,f#rv,fLNE1;F�VPnACtTtEM ULfHGT3 anJ/cr Hriuti.t Cll�lrGl.!aaavcialcd wlNf this o brut of teal Bavnas,and 1 uekonwlulgc that Vq <br /> lis Sim 1 also cenifY Wet all Infortnminn providtd on Nisapplicalioa Is free and correct;And tthat aU Mutated aedvlUeawia be perfon cdiin aaonitat" Nhor aLml n I pidlcatblc SnN <br /> mils COUNTY Ordinance Codes and/or Standards and S'Ta I t aMUFt: <br /> or ,T:wr.Laws and Rtgolalio u, As the madersignW owner,o <br /> D fneinly/site eddres. 1 hereby' amborirc the .el"m of BAY Add all reaahs and eRviroomenlal asa�'"*At IRlormadoe to SAN ICOA UIN the y.rolq l Mf,at the <br /> LTII DIV ISION as soon as it u rvailahle mud al the aaMu time it ie presides!to me or my rcprpenlatrva COUV NTY ENV IHONMENfAI. <br /> PLICANT NAME L <br /> Pi.E.A5E PRINT <br /> jl}- 1_4 �l vi(Jr SIGNATURE <br /> LE _ fkll�CCnT Gf-6LC)6IS77 DRIVER'S UCENSE# 03 ()!'S` <br /> ,"� <br /> /eHnTn[NW aepnncn} <br /> W:R`.!adY 4�F.�n'a`r=; {. ._a•_ _ y �,, <br /> w _ <br /> - _._. _ �z*r- IGrwvrs�IemaaynlaaaeaOlvp'B:-+�,�yla-'tea—F�.�,*"ri <br />