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04/17/2001 15: 11 2094683433 FIFTH FLOOR PAGE 04 <br /> INffi C, <br /> GATE I MASTER FILE RECORO INFORMATION FORM <br /> &R'= OWNERF,I,L I E WEER UNIT IV <br /> CoAfPL-wrET.�iCorGI40WI&A�-UU$INESS OWNER ImpoRm4r10CNECKIA 0WNfA mrmEHO 0 <br /> ............................ ............................. ................................................ <br /> PHONE <br /> 0INNER NAME 'r............---------_.--------- ------ W4- <br /> ...................... ..................2m...................................m ....... ...... ........... ..................................- <br /> Susmeas NAME(if d~ornt"m Owner Maine) <br /> 0INNERHOMEADDRES3 Licamilate <br /> Cleo, STATE zip <br /> 0INNERMAJUNGADDRE35 Aftantionc ow-Can,of(OpStantanf) <br /> i <br /> Mailing Addrama;City Stislas Zip q,5 205 <br /> Typo OF n.Rmm.p. <br /> CORPORATION)( INDIVIOL1,11.0 PARMER34HIP0 LOCAL AGENCY U COLIN"AmIsICY0 STATEAGCNcYC FilvAueNcY13 OTHER❑ <br /> FACILITY FILE <br /> Eli-1.5 RE <br /> W40" xmq— 5 RMATNEW 'wo HE 'M m WK5UT REM <br /> CoAfpLFTHrNEsroLLcw1mo BUSINESS FACILITY/SITE ImircliquArioN., <br /> 15 thiSa NOV18winess LOCATION not prevoilosalreQuillated"a VNVIRCNMENTALHMTHDtvksloft? ych, 0 No)< <br /> Is this an EXISTING SusIneas Locariontpurta NEW TYPE arregulataid(ItAimiln? yam; 0 NO <br /> 8U3IN1E331FAC1UrY/SIT&NAME <br /> &Z�h�Ir <br /> SITE ADDRESS q <br /> SQIY&At evsWE93 PHONE <br /> t I ts <br /> CRT <br /> S\'tZaLiL k� i STATE zip ctszcs <br /> CA <br /> ,67 <br /> 13F <br /> RAM... lip WE= 735111E <br /> Mailing Addrest,itrDIFFERENTftm FacuiRyAdialmss <br /> Al2anti011:Or Carol,WrOP0011W7 <br /> Mailing Address City <br /> STALE ?jp <br /> 07 F�5 V71 <br /> -105 _p�N <br /> m <br /> mmj=1=mF'! 101,11,111P ngai] MEN NEE 6 <br /> THiRi) PARTY BILLING INFORMATIONS COMplefff it Billing Party is different from Business Owner idiantiried above. <br /> ................................................................................... ....... ................ ........ ................ ............................. ......... ... ...... <br /> G <br /> ( Attention:or-Cart,Of liapharad) <br /> SUSINESSNAN <br /> A7 — At I;s zL,-(3;" kkk c <br /> PHOW <br /> Mailing Address W'LPeNLart- sem;tom. +ar- <br /> CITU STATE Zip <br /> kk,ci 6-01 kf,, I <br /> for fees and charges owmit FACILITY/StASNIESS C THflR1DPAJtTYS1a; <br /> ftmrr^F=. psrAto7795. zwo*=a2:YI Ar.w 'cmtAazs aasoai.ted with flaft Q"rb%W. will be b0lud to me at rho and, 149adifloW iba, m .a4<OLnT <br /> . DDRET.t Ill,this site. I also certify lb"all information provided an Ihig 2polkation 1.True and onroor; and Chat all regulated mtor ties will be perflamed in a�prdamcc- with 40 <br /> applicable W JUQULN COUNTY Ordiri.tv Codes*Adlw Standards and STATE and/or FElitam, and Rn.l.ziom .4a the undersigned mna.opemor."agent of the praperta <br /> located at the above ISOWNts What, I herby Ruthai2o the rothom or any and ad mwits and em"ro..'rital FN AQUIN COUNTY <br /> ENVIROKKENTAL K"TH DWI$=-man m it is available and it the s�note it is provided to the or my rc7rc=m a <br /> I <br /> P41ZAZE PRINT <br /> APPLICANT NAME MIJ k�A. SIGNATURE pyo. <br /> TITLE PV-Q�qv+ AkrXWjAr 4- ATL (At— DIRIVER74 1.10121469 111 Asn ILI <br /> _W99=00 rnuunnt <br /> qV <br /> Eli <br />