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1-61=2,4 2694626433 FIFTH FLOOR PAGE 02 <br />Vw IM GREEN FORM <br />PATI:. AR 7 2003 MASTER FILE RECORD INFORMATION "MFR" <br />" j' I � � F��I r /�L 1 �' ..__�rJ—.._ 1 r '°'". �.:� r; t� u �:'� ^�:.:, r �� Ohl �` Pa',t . ,�n..r: il�.. w � u r� . a S 1 ,� � � � ■ <br />OWNER FILE <br />.�_. _ ..nn�r,�nTv r►unatn 7�I�A/l�/IT/)lIf 0 FCXIF OWNER CU4PEN7IYONAAEW-r7HEHD <br />PROPERTY OWNER <br />NAME <br />( <br />FiYst <br />2si <br />CiUSDOGe NA14E <br />11 <br />SOC SIC / TAX 10 4; <br />owner Home Address 3 ¢ 3 S � <br />C�� a <br />DRIYERIs I10ENse # <br />azy,-M <br />SATE C A <br />ap <br />ovmer maillngmidress <br />Mailing Address City '54 b/, LA., er1 ( sm tip— ` ; Imp / <br />♦PF lYF rt1.IMFn4it0 <br />PryOMOLTTnT1 TwnTV.ry 1n1 El DADef CYTV 0 CCH AP_Y4— 1= ii'nNFB ❑ <br />is this a NEW Business Loc►rioN not previously regulated by the ENvuMmENTAl. HEATH DEPARTMENT? YES ❑ No <br />Is this an D=NG Business LOCA77ON bud a NEwTYK cf regulated Business? YES ❑ No <br />k I <br />BUSirIEss/FAtDLt7'Y/"� � i P/C N ��D�OGLLIL ✓• �ylTy4Z°5 l-©rp <br />Sm APEIRM SUITE# BU barm PHDNE <br />343`1 5�6A At r o+r lda �2'm 23--333 <br />CITY zv 9 5724f6 <br />77,11 E �9... u-+,�— ar!� I,..:.rr�n`:•A"'�;P, .r l,'T +.la`^.,0°; y ��; '--^I>�^��n1 -�,r �.1,. 5-,, r. •�c r,al,� �w'.`31��. 4:�;tld'i'fI <br />1 ,,r I % v aai A.4 s .r /�l+Y It 61 . 7 t• r. r i rel w. 1P�Fi i 'Pi SAL' '7 i; <br />1 L �4^� `N <br />Il° .,r k' 1e. •, In ti y" I � J i 1 si M "i ) 2 in,, Mi4 ` <br />Bo4RDiS1JPrJit25OR,bW75TAIGI.f �,, sDDNCO[�!.^w;. �"✓ _e..G.'�s's{ c_��.� `u.-�¢, :�„r.uf.....iu .. ,o._.csJ"�.. <br />Mailing Address WDVFERENrfMMF.Vj” rrAddres+ �tZnFr: or CaM Of (optowli <br />po"Boy (.�,u- <br />Mailing Address City ATE 2tP 266 <br />THIRD PARTY BILLING INFO: Complete if Billin4 Party is different from Property Owner or Facility Operator identified above. <br />Btt57:atE55NAHE _� n�jtion: orCBre Of (CpC70/f1�% <br />Mailing Address 2 i 2 CG( //wl� PH l '/ ! <br />CM W`V� U ` P4— STA7T ZSP oAt'/T / OGI� <br />for fees and charges OWNER FACILITYIRUSINESS D PARTY BI <br />L the undmtsigned Applicant, certify that I ant the owner, t�prt ero , or Aurlrori:cl Apure of this Susioess, arch I ackno�dodgc that all PER+rf7 FLias, <br />natT�s, FNmacj ehuRCw and/or HoUR i'CR"aEs assoclated with this opemdon will be bOled to me at ths: address Idcodfied above as the er'r ny,' 'r •tDo eFsr for this site. I also certify That all <br />orrnadon provided on this application is Rue nod correct: and that all regulated acdvidis will be performed in accordance with all apphieable 5 JoAQU7N CoLV1Y Ordinance Codes and/or <br />tndards and STnn: and/or FCDERAt. Lu..s and WpilAtions. As the undersigned comer, operator, or acent or the property located at Moab fasiliry/site rest, crony auo/oFu <br />y and all results and environmental assessment information m Sale JOAQUIN COUNTY ENVIRONNIENTAL HEALTH DEPARTMENT ar soon a It is ptJ q� <br />ovided tome or my representative. PLEASE P� C 1-m 92 � � 4� V 37eY� 1 UU <br />►PPUCANTNAMe �(Z�Q�G� (1�T2� SLGNATu <br />m� // � RNER'S LICENSE tl <br />Prc�l`�c� n� �t� ttkC p PHOT«ovrtrEl UIFEpl _ <br />