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tire"31 <br /> mem <br /> GREEN FORM <br /> DATE _ MASTER FILE RECORD INFORMATION I;1 <br /> �d 4 n , �_ UNIT IV <br /> ryv = h <br /> 190035%WNER FILE OWNER Lyois aEWIrHEHD ❑ <br /> 0/EdCIF UnREIYR <br /> COMPLETETffEFOLLOWJNGPROPERTY'OWNER INFORNAn7ON: PHONE[ <br /> PROPMNOWNM � . ( <br /> NAME �,e l.. <br /> FksY MI lag <br /> Sm SEC/TACID# <br /> Bassets ss NAME <br /> 1 DNEVEIt # <br /> 'SLICE70 <br /> Owner Home Addms :.2C— �� <br /> City J '\ sr. J Sa ~' <br /> owrNr Mailing Addres <br /> Sete LP <br /> Mailing Address CRY <br /> Du'ro�� ncv er:vury❑ muco❑ <br /> 11111111,111,11121! E!11 E <br /> .-. �,�+� .. Vii^;,;s.. <br /> fr .a L M- Dt n S <br /> _ <br /> OMFL TH O <br /> YES ❑ NO/ul_ <br /> I5 this a New Business LOCATION not preViouslY regulabed by the EN oNMEMAL HMni DEPARTMENT] YEs ❑ No <br /> Is this an Bosr1MG Business LocArION but NEW TVPE of regulated Business <br /> Busrnt3:./FAO>•IrY/S[tE � � r'. <br /> soamEss PHONE <br /> SIrE AopltEss - <br /> STATE (�Zm <br /> Cm � +R <br /> flxiE . rns ret m _, <br /> "EEE3 <br /> Attention:or Care Of aptiona/J <br /> Mailing Address ifolFFERENT om FadlRyAddr121Os _ <br /> STA <br /> Mailing Address CRY <br /> I - <br /> THIRD PARTY BILLING INFO. Complete if Billing Party is differerrf from Property Owner or Facility Operator identified above. <br /> Attention:or-Cam Of (optional) <br /> BUSINESS NAME " <br /> PHONE <br /> Mailing Address <br /> STATE ZIP <br /> CRY <br /> A=QffA9AD29F5S for fees and charges OWNER FACILRYIBUSINESS THIRD PARTY BILLING <br /> and I acknowledge that all PEJUBT FE <br /> R —(• a ssn rnrvrTNr: I,the undersigned Applin^4 certify 0a[I am the Owkr,Operator,or Authariud Age.,of this Bniness,A nnRRer[or bas"m I also certify that <br /> PENALT/ES,EN o mvEw CHARGES and/or HOURLY CHARGES associated with this Operatioo will be billed to me at the address identified above at the A <br /> information provided on this application is true and ecrrecry and that an regulated activities,will be_performed in accordanceatort or agent of the propertY 1��h an at the applicable <br /> bove ble S y/s Ieaddre AQM C f Ordi nt�the III <br /> Standards and STATE and/or FEDERat Laws and Reguiatioos As the undersigned rntlyy[yrENVIRONVIENTAL HEALTH DEPARTMENT <br /> as soon as it is available and at the carne close' <br /> any and all resdb and enviroomental assessment bdgc1 udun <br /> provided to me or my representative. <br /> P —� <br /> LEASE PNIAT <br /> I ��� <br /> APPLrCJ1Nr NAME._ / � � l.V t PU ZMrNATUP3 <br /> 4'�/ DRIVERS LICENSE# <br /> TITLE (PHURlI NEOU> <br /> �I�t�jx�W BY �e�..�'�- Date a �I � n90f��Prt'�IiMiCoiflpletetTikY' aata��+-. -a-- <br />