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b3i'21/L6QB, j <br />DATE JAR 2 7 2003 <br />FMA •v fire -t <br />i'r_PdT HEALTH <br />23346334 <br />FIFTH FLOOR <br />MASTER FILE RECORD INFORMATION „ MFR if <br />PAGE 02 <br />GREEN FORM <br />UNIT IV <br />L1 -r -'::;i t �SLFiV��C� (/w Vt:yv�% ✓Gti�tii➢ER F[L.k <br />• rI�• (?rFptrF OWNER CuRVnrzravflrFwrnHEMD <br />CoMPLMTHEFOLLOWMGPROPERTY OWNE INFORMATION. <br />PROVERTY OWNER <br />NAME11 - QQ s r7�•-e s Cd o 6Y� <br />PH PV 3 <br />First <br />Aft wl <br />Riteaiaet NAME JA n <br />W I PK �errf U cu(25 m <br />Sot SEC / TAX ID it <br />�z[,� . <br />D(tII,rER'S LICENSt: # <br />owner Home Address AA <br />c- <br />04reer KmAing Address V 1 <br />zip <br />Maium Address Cit a� (jt� <br />MrFE ,F n.....FIEt .o r�-I <br />Cm ar:vury IJ An+cs <br />Pneenoarrnw TunTV.evtar e►❑ assoTsteeeuro ❑ <br />�A B Qd IQ L�a' F�C[LiY �, <br />r�r Lw^".6--ti'"' �k Y � r�l�f+ �''"'i�F,1 f'�f•�'� `a ti� � <br />Y`eS El No . <br />IS 4115 a NEw Business LOCATION not previously regulated by the ENVMM0' NTAt H itt DEPARTMEIVT7 <br />YES ❑ No <br />is chis an E NG Business LOCATsoN but a NEwTYPE of regulated Business ? <br />BUS7ttESs/FAtl1iTY/ NAME COIF <br />l-� i� �p PHOra <br />sulT z 9 q <br />srrEADortFSs n /h i %�C L Vv �7 (Z <br />CM <br />BO_AR+DDM$UP�[0.�F.a0R�b � i�,t tr?;r J,Z 0CATIX <br />Mailing Address 1YDLn SREN7f1tuf7" Arldrt s <br />P, "a 0\,/- <br />Malling Address C4 aC)CL�(� <br />CrATE z'P 9520 <br />cam Of (Opbiww') <br />�5 266 <br />SiiCOR4wti C. :.a_Y .- �r.ia•;r �,.. <br />'HIRD PARTY B/S dl <br />BILLING INFO: Complete if Billing Party f Brent firm Property Owner or Facility Operator Identifned above. <br />ration: arcare or <br />�(O"pi tic v <br />5,0 <br />dstMaiiingAdP4ei <br />� <br />�/ _L �n / ' n13 <br />$TATE ZIP <br />CRY <br />FACILrMtsUNINrs�- <br />NO] <br />-- - - recur or.tWheri ed ACurr of this Susioess, anda.+d I ackno vWgc that all PERMPrFBes, <br />tyy-�.- .±nfn.�trt ewu srtLy�lVt.GAl:�trxS; I.. the urtdersiptad Applicant, certify riot t am the tiwxcr, + ��yM,,....tD for G1i5 site. I also certify that all <br />W.tLT.fFS. ET'FORe0,W&eJ "CE5 and/or HoAxLYeR"C�c associated with this operrtion will be billed to me at the address Idcodfied above as the <br />ortnadon provided on this appl cation is true and <br />Cornet: and WE all re9tdatcd =Ivides will be performed in accordance 1� ^d atjheapplicable <br />;,b lwv f-ca+� `r I, r-1, "C y a tnnr;zo h�rele w�of <br />utdards and $TATS and/or F&DM',L L"r" and Rc�etationr. As the undersigned owner, tyforator, or scent of the pwPU9 <br />y and all nsttlts and environmental assessment irdormaGon to $aN lOAQUiN COUNTY EN`VIROtM1I2ErN7TAL HF.*<I TH bEpARTME� I as soon It is a 1° and at the sam: time It Is <br />ovided to me or my representative. PLEASE PRIW p 9Z5-141- J <br />��lCl SIGNATu a <br />1PPLICANTNAMO `G-� K }.1 �•iE� <br />ER'S LICENSE <br />(PHOTOCOPY REQViAEDI <br />