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MAY 07 '02 09:04 TO-120946711 FROM-Insight Glass T-421 P.02/02 1-852 <br /> �sm�r`er��r{ '01600% <br /> '�-,xr -?F a-�=a a'�, � rsrn��.r 1,�*�.*,rt t•�y,�. ��'�`�, IZ 4-ra-� <br /> e;i1i2'.< .1a_'P."�"ir•^'1.'1M��UI,6I�Q 1F' �q ��yy�.'.• Y!.'�'tl"'�'}n. <br /> -����������7^k :;.r�'1.�. <br /> DATE r <br /> �- -� O� MASTER FILE RECORD INFORMATION "MFR" GREEN FORM <br /> $LS➢LO.APIrVLf , ON <br /> UN1T IV <br /> ii; <br /> I O -7 »< OWNER FILE -- T <br /> COMPLETETHEFOLLOWIN6PROPERTY OWNER INFoRMATIom Cxear,F OWNER CURRENnYON FILE tvmrEHD ❑ <br /> PROPERTY OvvNat ' PHONE <br /> Na — ----- <br /> NAME �vr ISe�epo� -70'7 -?/ _I <br /> Fi cf MI bx <br /> BUSINESs NAME f J Soc SEC/TAA10# <br /> Owner Home Address DRIVER'S ticEME tf �b3 9 <br /> City / STATC tar <br /> Ovnw Maiifr0 Addraas CA <br /> Mailing Address CityAjqSts Zip <br /> jq -- - - - <br /> •TYPE OF OWNERSHIP <br /> CORPORATION❑ awDIVIDU PIIRTNER"P❑ FED AcANtcr❑ CmtER❑ <br /> FACILITY FILE <br /> =� i :� '':i• :� �},. � , .� r. 'trig, a��Sf e - <br /> n,..�y�,� , h {�r.�r(� <br /> l�e�i'� ..-:rk F f's ;-i'+4 <br /> S <br /> COMPL£TETHEFOLLOWING BUSINESS/ FACILITY/SITE INFORMATION: _ <br /> Is MIS a NEW Business LocAnoN not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ NoD <br /> Is this an ElasmG Business LOCATION but a NEw TYPE of regulated Business 7 YLS ❑ No <br /> BusixEss/FACn1V4ffE N <br /> SITi ADDRES6 2 t 3 ��Gl. � �o� � eusr�PHDNE 3 9 8 <br /> zf� --y <br /> CITY STATE ZIP <br /> tl.,t1 3Xri'/+�.:5:`C �,�"I�^i("�.• •O.'.tt' �;"�'y r '� ty.� xLif. .{+p� ; !1 +. .z� .f��fq._1 _I y 4,��Z.--Ll`JL,"'/ <br /> lfirl' .c :i.v •':^'�' :v 1. I".e�?'�SYS9}Xi6S;.�.,7„-'_EM,� 5...�'�.F'WN"".: L'-AX 4'�':'i.l.. r �w.'��1. `aF' 'iii'.�`::'L•3�i:;i-i:�dS44r(J�y_r_.� <br /> Mailing Address//DIFFEREAfrfram Fad ityAddress Attention;or Care Of(opdurre/) <br /> Mailing Address City STATE zip <br /> 4p' <br /> THIRD PARTY BILLING INFO: Completeif Billing Party is different from Property Owner or Facility Operator identified above. <br /> BUSINEssNAME Attention:or Care Of (optional) <br /> MailLtg Address PHONE <br /> CITY STATE zip <br /> l Acaum Ammircc for fetes and charges OWNER FACILITY/BUSINESS THIRD PARTY BILLING <br /> BILLING AND C06IPt.IANCE:%CKNOWLEDGAIEN'r: [,the undersigned applicant,certify that I am the Owner,Operator,or Authorized Agent of this Business,and I aclutowlcdge that all PAAW11'FeF-s, <br /> PL'VALTTFS,ENP0RCEa1P-NT Ct/MGFS and/or f ouxl yC:l.IRGf r associated with this operation will he billed tome at the address identified above as the.•1000UAT ADDRFSS for this site. I also eetlify that <br /> all information provided on this application is true and correct;and that all regulated octivities will be performed in accordance with Ali applicable SAN JOAQUIN COUNTY Ordinance Codes and/or <br /> Standards and STATE and/or FEDERAL LAWS and Regulations. AA the underAigncd owner,operator,of agent of the property located at the above facilitylsite address,l hereby authorize the release of <br /> any and Ali results and environmental assessment information to SAN JOAQUIN COUNTY ENVIRONNIENTAL IZAL'rtl DEPARTMENT as saou as it is.vailablo and sr the same rime it is <br /> provided to me or my representative. Q f <br /> P G�� V <br /> APPLICANT NAME - SIGNATUM <br /> Trm jay, e` DRIVER'S LICENSE# <br /> (PHOTOCOPY REQUIRED <br /> 7ArKP, �r's_`„S+a�:�af.,��"-�=� ?•��',� y�, .,y�, .,f� a � ��_.' ���_�•�f.� `. �• �`i�4r'�:. <br />