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<br /> C4/17/2001 15:11 20946 3 FIF H FLOOR PAGE 04
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<br /> GATE MASTER FILE RECORD INgfORMATION 1 ' �(
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<br /> DC(J Q l o?lv 7.2 OYIfNER FILE
<br /> COMPL£T£7NE FOLGOW/NG BUSINESS OWNER lNPORMATJON: CRJicxrs OWNER e.... vGNeR,E wl7NEH0 ❑
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<br /> IdU91NF99 ! , \6'/� •••A•• ! �fQ✓/�L\q PNON! rt��
<br /> OeMERNAME :--- _______—. ___________________I T
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<br /> iduSINEs9 NA2aF(IT dilrerant lrom Ov+rwr Name) �D�LaT Ce..�+-o. � SOC$ECl TAA 106 :
<br /> El"CR HOME ADORE" J 1, I, ORIVeR'S UCENaIp
<br /> Cin/ . STATE i Zm
<br /> OWNEAAINLINGAoORE9s (ieOJFfERENTfrnm O1wner Addiec(s�/ 1 `^ ! Attention:wCa.v of (optfonaQ p
<br /> Mailing Addraaa city �l`3 slw%a � (C.`OaQ S�c,L��� State Lp L5 2oS
<br /> CORPORATION MONIOUALC PARME03HP❑ LOCAL AAENCYC COWTVAOENCYC STATE AGENCY F AoBNOT❑ ur} �J
<br /> li4/a�.33 FACILITY FILE pp
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<br /> COMPLETE TN£FOLLOW(NG BUSINESS/ FACILITY I SITE. INFORMATJON: y
<br /> IC Dim a NEW Suoinesa LOCATION net previaufiy regulated by trio ENVIRONMENTAL 14 l 714 DIVISION T TES 0 No ),7
<br /> Is this arl al3TINC Bualneas LOCATION alta Now TWE of regulated 0401inea9 7 Y69 ❑ NO Je,
<br /> 9U$INE35IFAGLITY/SITE IdAMi3��,} �`
<br /> SITE ADDRESS 1 1 + SNTFp 0V�91peJE99 PHONE R czI
<br /> CM S�t � •i STATE ZIP CLS Z�
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<br /> Mailing Address rFOJFFERENTbwe Fxd&YAddMb -- `: Attention:w Care Of(dptio")
<br /> Mailing Address City i STATE i LP
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<br /> THIRD PARTY BILLING INFORMATION! COMPiefe if Billing Party is different frCM BUSineSS Owner(dantifled above.
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<br /> QU91NE9a NA" ! Attention:arGare Of (apactld)
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<br /> Mailing Address 61`� I 1 � SJ; <� 6 PHONE ICD! 5}q--u-Lq
<br /> CIT/ �� aTATfi �(J LP f
<br /> cC forte"and charges Woritt FAci. Y/BUsbus9 THuen PARTY BIt.Lw
<br /> all r me.AN8 Cevfr sA m\OsovOws ra,.v ,j: L rhe undenigaed ipPilcant sonify that I am the 0.,,OPoawr,or.b4h1 i'sd ASIn,of111 s usmov,and I arLo.awledge that all
<br /> PEAS!!'fCE5, PSM4VUS.ENYOACENTAT CR ROf4F-ndl.RovKr CJGRCLS 253malcd with this epermion will be billed to me at :ho addra.e idcmifwd above as the ACCOI'.,T
<br /> abeEts for this site. 1 .130 certify that If information provided on:hi.appf'carion Is tree.4 c91w; and that all revgalatad aetorties will be performed in accordance with all
<br /> app(;eable SANJDAQUPI COONW Oidinan<c Coen end'ar Standards and STATE andiar FEDERAL Laws and Rcsulations. As the and ni eed��'owaJJPtIIIert�a�C{cof.QB ''FF of the prop"t)
<br /> laemed at the 2601, facility/sin addrms, t hems, authorise the reMue or Atry and a0 raaulM and enviromm�Nal osxc,s :l'fdi+ qt F�'.R1{Y(• QfRN COCi n,
<br /> g,lVatDpME`TAL HXALTht DIVISION as noon as it is ay.itablo and et the lame time it a provided to me a mr repracotativA I�II—I U C L
<br /> t� 1 I PLEASE PRINT
<br /> APPLICANT NAME hfltvN VQkvl AG; I ,, SIGNATURE
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