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tf -e 10^21-1998 2:39Pt4 FROM 0 P_ 2 <br /> WRN {EH ao 13(RENe3ea 08I11nT1 <br /> DATE 1 0- KOy- 0,6 MASTER FILE RECORD INFORMATION <br /> UNIT IV <br /> OWNER FILE <br /> COMPLETETHEFOLLOW/NGBUSiNESS OWNER /NFORmAnom CECKIF OWNER CURREN rGm F11XnfTHEHD Q <br /> 1'aulNEss i Tos[o .' D�t•r¢�tduTlOri Gtyr^tVifTN ` <br /> P ioNE <br /> ow"NAME -------------------------- -------------i 562 9D6- '+563 <br /> BUSINESSNAME(1f WR9rentbvn DamK Name) SOL SECT TAf:lof <br /> Owmm HOPE ADDRESS 964S $hc1-,+ FE se2.irA US R N :` DRIVER'S LICENSER <br /> Gtr SArnzn- F-E SPD.1tA6 STATE G!� zip 9O6 0 <br /> OWNER MMUNG ADDRESS (ffOIFFERENTfr Owrror Adri—) A1LBAtion:e.-Care& (optiorrat) <br /> � Cz.. 3lr^'� Aogwts <br /> Mailing Addiesa City Sete '. Zip <br /> ..yay....ATIDN INDMOIARLD PARNEReIUP❑ LOCAL AGENCY❑ CoVNrt ACENC 0 STATEACENLT❑ FEUAGENL70 OTHex❑ <br /> FACILMY FILE <br /> A} h'-:1:t "r ... <br /> W- 1 <br /> .s' ?1' S'.il bT[AA' '115 'd 4! x <br /> COMALE ETHEFOLLOWING BUSINESS I FACILITY!SITE INFORWTION: <br /> Is this a Nm Btalnesa LOCATION not ProviorWy regutlted by One amRONMENTAL HEALTH 01MION? YES a No 1,�v <br /> is thC an EDsmmc Bnainelo:LOCATION but a NEW TYPE of regulated Susirms 7 YES ❑ NO <br /> BVSINE33tFA(aUTY=TE NAMEpp tt�� <br /> Tosco gelLI- PLAK-f °� V D <br /> SITE AooRE33 SUrE SMINESSPH17 <br /> 5-tiLEE N(h nr'A <br /> Qrr -rQAC.`( STATEC Lv <br /> .tl�'3•� <br /> 11'PQA(FSO <br /> Mailing Address ifO/FFERENYfrcm Fa XfyAad+ Attantlon:or Care Of/aptiareq <br /> 'fi'LSco 'D Lica l3u-i lar+ <br /> Mailing Addtese City6P�H' SPI..u' ""TEA, aP q 06`70 <br /> °1645 s ttrt TA Pc SF L1µlcS RvRD <br /> THIRD PAR77_BILLING INFORMATIoN: Complete if Billing Patty is different from Business Owner Id <br /> .•.•BusINF33 NAPE ••••••___ .._,. —� _.._..-....-_ ..._..._.-_......_. -.-.��_______(o�r .. O <br /> Atmndwr:uCare Of <br /> NOV 1 7 1998 <br /> Mailing Address ? PHONE <br /> LTH <br /> Crn ' <br /> STATE ` yPPERMIT/SERVICES <br /> AeGOUA?ADORF:r_ for fees and chargos Ownlax FAcnxN/BuswEss THIRD PARTY BIwNO <br /> R tlmf.AMn COMP iAN('E ACavovYl.EtIGM}TT. I,the andemgaeApp6cmal.rartify tWr I m tk Ovr .OpeAror,aAad-e;odAXenf.f t66 Bosine3l.and I acinowladga that all <br /> Fm,aT Fra, PZNA vm, ENFORGENENT QLfR and/or Hoo r CHARGES 23aneiated with this operation Gill he belled 10 me at the add. idrnlified above at the ACcoiwr <br /> M�for this site. I alNr certify that dl informeuon provided an this applieatioo is nae and correct: and that all regulated rAivilies v m be perfemad in acmrdancc with m <br /> ApplioWe SANJOAQom'Col, Ordinnom Codes and/or Standards and STATE Gnat/or FEDERAL Laws and Regahlions AS the needmsiSned o vrim.oparalor,or agent of the-properly <br /> located at the above facility/sits add., I hereby .athorixv the rcicase of any and W revolts and onv`anmental asseesmott-information to AN JJOO�AAQQUINUIN COUNTY <br /> ENYII201'1WIBNTAL TTR r TIi DIVISION a sono a it is evadable and at the soros uo.e it b Provided to vee a my repee.emative '�`�" <br /> ' PLEASE PRINT <br /> APPLICANT NAME MR._, aJtvt RpAMs. SIGNATURE i <br /> (� DRIVER'S LI ES <br /> TITLE <br /> l�2 MCDiR'T 1orl �RqJ e-cT AAAa.1 R'C eR- <br /> 1.._,arr+ t <br /> I ?.+. <br />