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6i/02/2002 11:09 209415F- -93 FIFTH FLOOR PAGE 04
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<br /> FORM (EH00t5lRcrt3e0oen1f97)
<br /> DATE MASTER FILE RECORD INFORMATION
<br /> UNIT� :�t��t�N��Q�k�n: ,.'tae e, • :s" Irx�>��,�;7''`fir,;" !! �r�`�<�� �- s�:':k s. V N I I
<br /> 10,� ;4flINNER FILE
<br /> COMPLETE THE FOLLOWING BUSINESS OWNER 1NFORMATJON. cvEcKi� OWNER CuaaENrcroNFitE a�nrrrEHO
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<br /> BaslNess \ C,o rt.ar c. V S
<br /> PHONe
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<br /> OWNER NAME- -- — —i—
<br /> :7rat ............................4f1.............-............____.._....... ......_...........................
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<br /> .......................---..._.............__-. -_
<br /> Soc Sic J Tax ID a
<br /> SusiNEsS NAME(If dh%Rr8ne from Owner Name)
<br /> F_R HOME ADDRESS DRIVE'R'S LICENSEp
<br /> OwN
<br /> VO-7 IV. Ssk%la C r,,z-
<br /> �n STATE ZIp 9 S 3
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<br /> OWNERMAILING ADDRESS (if orFFEREN T from Owrfer Address) i Attention' orcare of (opeioraQ I '
<br /> C-x0 e-C,�yeS _
<br /> Mailing Address City State ZJp
<br /> CORPORATION Q INDIVIDUAL❑ PARTNERSHIP LOCAL ACENCY Q COUNTY AGENCY C STATE AGENCY❑ PEO AGENCY❑ OTHER❑
<br /> o FACILITY FILE
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<br /> COMFLETETHEFOLLOWING BUSINESS / FACILITY I SITE INFORMATION. t!
<br /> Is this a NEw Buaineas LOCATION not previously regulated by the ENvISaNMENTAL HEALTH DtvlsioN 7 YES ❑ NO yr.
<br /> Is this an EXISTING eusinesa LOCATION buts NEw TYPE of reguiated Suainess 7 YES ❑ No
<br /> Wi6tHt'3311�,lt?tb: /SITE NAM t- A
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<br /> SUITE At 13USINESS PHONE
<br /> SITE ADORESS
<br /> M�w STATE ZIP
<br /> CITY
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<br /> Mailing Address ifolCFERENTfrom Facif;tyAddrass i Attention: or Care Of(opGaw!)
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<br /> ✓LLa r 4.C, dE I'LL s
<br /> Mailing Address City STAT ZJP yat$3
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<br /> THIRD PARTY BILLING INFORMATION: Complete if Billing Party is different from Business Owner Identified above. ^
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<br /> BUSINESS NAME Attentio or Care Of ( )
<br /> IPO C,
<br /> 1 T � �.
<br /> PHONE ;�`
<br /> Mailing Address
<br /> 13 2 Co Al �,r 4f TS I ve( ( ) ` 7
<br /> CITY STAT zip
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<br /> IS"C gr 0. it
<br /> gC OBREss for fees and charges OWNER FACILITYisUSiNESs HtRo PaRTY IWNG
<br /> Ru r rvc wn CnntPLIAHrF 1etCrowLED:XE`sT: 1,the undersigned Applicant,certify that I am the Orwfer,Dperaror,or luthorieed rlgof this Buinr and I aelseHledge thu all
<br /> PERVIT FEES, FEN.IL7TP5, ENFORcrvZ?'IT CHARGES and/or IforrJtLY CHARGES amodatPd with this op—loo will be billed to me at the address identified above as the--0tlrotwr
<br /> A,qnREss for this site. 1 also certify that all information provided on this application is true and correct; and that all regulated activities will he performed in accordance �-ith all
<br /> applicable SAIV.IOAQUL`t COtNTT Ordinance Codes andlor Standards and STATE and/or FEDEF,U.Lays and Renulations, 1:,the undersigned owner,operator,or sent of the Property
<br /> located At the above racility/site address. I hereby authorize the rolease or any and all results and environmental Wc.-5.r enE information to 5,*Q4 .JO tQUIN COUNTY
<br /> ENVIlRONME`rTaL HF-%-LTH DIVISION as soon A it is available and at the same time it is provided to me or my representative.
<br /> PLEASE PRINT ,
<br /> APPLICANT NAME 1 / SIGNATUREUnu-t�,'/,
<br /> DRIVER'S LICENSE#
<br /> TITLE r^'- Rte^'
<br /> ` >1YaaYStsritii�g'.
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