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N <br /> y <br /> ' �`:. i �r+r•,^ - _ , a nt,,., __ :�-� - <br /> 114 7 a Q(? MASTER FILE RECORD INFORMATION "MFR" GREEN FORM <br /> UNIT IV <br /> sa.eF.,.wc.a•cReMa:n.tiM^ r� k .� � N <br /> � <br /> _ OWNER FILE D09775 <br /> 91WPLE7ETHEFoLLowiNOPROPERTY OWNER AVORMA770ar.• CHLcn/t+CWNER 1.0WW.-Vrt.r4xFX wr.MEHD <br /> PROPERTY OWME3t 1, PHONE <br /> NAVla rf C?-c -rR Rev <br /> �'rst All test <br /> EMMEN NAtRe NUS L C /v f'f - SOC BEC!TAIL 10 0, <br /> Owner Home AtddreesDRIVER'S UtIelet 0 <br /> CRY srAr4 xtr 53 76, <br /> 1 <br /> I <br /> o mer f»h r <br /> state <br /> Mab Address City <br /> FmA11[MOY C"IR <br /> POISIOMDUpalrrwERSHIt+ d D/1 5 1 f <br /> CORRATIOAL N❑ I qLa LITY F1Le <br /> r. IN <br /> ;s <br /> 0=05-21 <br /> .,; ., e ; <br /> .. y T/Qt tl: <br /> Z o0MPL�TW FoiLt7lNiNG BUSINESS/FACILITY l SITE f y Fj (3 NO ❑ <br /> tothinaNfw Buolneea LOCAT1onn0tprevlOttsty ret9u � the Ed1sAROHhIt ffAt HEAk3H Q,VIa10N? YFS ❑ NO ❑ <br /> ha t1'iie an Elaanns:gualtteaa LorATKM txu 3 WNTYPE ort rtspulG,leed'8ttlJrtees 4 M y <br /> BUS.&-SWFA0Anyj'&TE NAME �E'�r /!A� 1 (�2 I • �/✓ r•� <br /> STTE ADMIESS J1 rJ ,i BurrE 0 Bt1a*=S P40M <br /> I � aP <br /> Filling Address)fD*7rREMrfmmFPcilf1yAd&► Allerdlon:or Cans Of(apftng <br /> I Mtefhng Address City STATE LP <br /> h <br /> Tiiffto putTr$fiilFLa I>KFt 'COmp/ete if Billing Pargr is trent From Property Owner or 1-scuity Operator identified above. <br /> 4 eustNESSNAhlE AeAribOn:orCmeof fwffmieil <br />+��`1lRathnp Ar9dress "`"�""'�"'-"�"'�'�"—• -�" � 'PIIOttE _�°""__. ��,i <br /> I <br /> CITY STATS ap <br /> W fees and ctmiges OWNFR FAGILITYISIISINESS rkQRlo PARTY BILLING <br /> c+r,: 1,it:e undersigned Applicant,cerdr)that t am the Ow+ter,Opuytor,or Apr.6arf;ed.AgeAt of iiia Burineri,and i%&Rowledge that all A?zWT Ff.PS. <br /> SSLLi�,1NI7 CCMrt IM'CE,3,`K��itivi.r.tsc} <br /> PETAL rJPa,EW0RCEim1K--CH,9RGFS anti,'Ctr ApL'RLr CJ1,tRGrS auu4ated niththlr operatiou wUl hr billed to she at the addrast Ideadeed above At the ACM06 Aap,7ES5 far thls site. I alfa terrify that all <br /> information proAcItcl on tits Appkauon is true and correct;and that all regulated activities AIR be performed in accardaace with all appikable SAN dOAQutrt COWN LkrdloMwe Calan andlor <br /> Ssaobards and$TATE aadror FEDERAL Lews and Rtgtdations. As the undersigned cwner,operator,or agent of the property located at the above faclHip'tite eddras,I hereby evt4arize the release of <br /> say and:Il results aW gn%rmnmentsl asatsatnaRt Iafor 3W4 ro SA!JOAQ1.11IIV COUNTY EN1 RONAJEWAL HEALTH DIVISION as roan as It is avallable and as The satne tithe it is ponvided to <br /> wit or my representative. - 1 <br /> PLFI�SEFRtNT !`I <br /> APPLICANT NAME slouxwliE t - <br /> .F TITLE—�� a�J 0 , = _ RIVER'S LFCEN6EIf v . ....__ <br /> PHcrM= RE IR <br /> 11 ENSURE <br /> "J <br /> ER <br /> ZO 39 d 0i7�M H-L.1Id £�4EC9bb�i� Z£ 5L 01213Z/61/40 <br />