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•i - � <br /> San Joaquin County Enyironmentaf"Health Departmebt <br /> DATEMASTER FILE.RECORD it+1FORA9A710tV s=�R1=Rg: GREEN FORM <br /> :1C <br /> :1,o` r SITE fl1If71GATION&LOP <br /> or;�tettl f- .#,'SUQUNIT til <br /> tiMEltigLE:CompLEwrHEFOLLoMNOPROPERTY-.OWNERINFit?RAfAnOM.' GAEcxiF.0WNER0uRRamraN#7Lc TmEHDE]. <br /> Fltact X11 [sst PxtittE Nt ' <br /> Btrs wwtiNAPE - 64MILAtiiteena <br /> owner Horde Ad*esa <br /> CIN aTATF XtP <br /> Owner Mtllptrg Adam= IC <br /> r. <br /> plulgngAdefressC Soil <br /> P. <br /> S�1po�1 <br /> C09Pl1RATtON© INOMDUALO .. . Prirarieaa[] .FWAQPNCYn Crt:tER' <br /> &M A4fIE OMON_EWROifA@fl A 1/DLWffd1W CLM —LATEST QirlUJW_HW PIMJNB INv.wn AC'nCM L.OP <br /> ` / Aa7_e �oYAACtY.IDd AcCoulD PR iOC EH <br /> CB�" DTBC EPA E <br /> FACILITYPILE ComPcE7ErnFi<accowwBu81N1= WFACILITY/WEINFoRmArox.- <br /> Is this a NEW Sualness'UMAMON not previously regulated by the EwRoNmENTAL HFA III DEPAR2'1'tIHEMT? YES 0 No <br /> Is this an Ewtin>ya 8ualhow I ACAT"but a NEwTYwof regulated Busitlese7 Yes'i] No. <br /> WMAopREop - +.�. Burma SUMNEDO PMNE <br /> aTr IPO STATE(A LP. <br /> BtEAttDOFBuPERVi2fORDimm= -. LLaoATMCON Keil :lt&2 <br /> Mailing Address MOIEFEAEiVl'lh=t< Add}_tay. ,Att9*an:orCtsro Of,f # <br /> NO <br /> lJtaftAddr—Qly. AOh t a 'STA+EQ fk,4?AP r <br /> 8iCQooe APN#, �� <br /> } <br /> r <br /> i <br /> THift PAKw BILLING INPtrf Comp/ea if Sifiing Party is difforient from Props 0wrier.orFaeility Operlator:fdenlNiedabotie. <br /> BUMEMNAttE Alto tloti orCare Of ft fiwiaO) <br /> MaTlingAtldrese. ' 'PHtxlte <br /> am Sr E Zip <br /> A=w9MCAAMW for fees and chargea OWNER FACILrfY1BU3f,NESS THIRD PARTY BILLING <br /> l .IILLiNG.ANo COMFLTANt:$ACCXNOWW,,pi;OFNT:'1,4be endersigned Applieaat,certify that I no the Owner,.bperafar;orAutharttedAgear or this.Business,and,1 acknowledge that sit Pi7tsffTF=. <br /> i Pt7`Af. "FNmRCr:mvr'Cm4RGssand1ar'flawmrCtturC amociafid irgh this operation will be trilled tome sit the cddrew Identified above for this 3 tr 1 alsa certify thm <br /> I all information provided on this.apgllcatiou is true and eot W,and that all regaintrd atfivitim will'be per armed in acrardance with nU applicable SAN J&Qttna C0101n.0rdloance Codes Andlor, <br /> e Standards and STA maadfdt I MERAL."W5 and Itegalatioas.:A.s the undersigned osrnte;operalor,or agent of the prapttiy located at the abovcdarilityhiteaddicis,I hereby authorise the relsse df <br /> any and ail resal4 aad.eaYiioamrrital asiessmeut informefioti to SAN JdAQUIN CQUtVIY ENV(1LON]N[EMAr.HEALTH REI'A)1 ENT.aswoni aa:it-is uvaiiahie and,at:the same tiine'is it <br /> pmided td we at my repiamlativc, <br /> APPLICANT NAME(PLEASE PRENi,) SIGNATURE •.. .-� .` , <br /> TAX ID V <br /> Crry ENCTN&,-!L Q� C,QOd? �o <br /> t OEfiAa l rccasoi bale 1001 <br /> BriE MErtaATiON Artimr lamo OF rAYupifT PdraEW TYPE fteGEiar &E=.ox V_ ],RE'Cer,=6V t WglR PLANPE- <br />