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2E54EE-,4FIF'{- t' OOP. <br /> Uy„nvnv u. MOMer -01*0 <br /> iMiry <br /> FORM <br /> MASTER FILE RECORD INFORMATION <br /> -w • <br /> UNIT IV <br /> OWNER FILE CxErKIF OWNER CURREAqLr&mFX5*?rHEHQ <br /> 4fPL,ETE THE FOLLOWING BUSINESS OWNER INFORMATION: <br /> ......................... <br /> PHONE <br /> K2 r <br /> WNER NAME ------------ ---- ---------------------i <br /> .."................................ <br /> sjNeSS NAME(if diffir�t fion,Owner Name) C) <br /> sosqcjTAxID* <br /> DReFER-SUCENSEIII <br /> "CA Home AODAEsz <br /> y MATH zip <br /> vHaR:MAIUNG ADDRESS yforFFERENrfiw CwnerAddreea) i Attsertioncarcarne of (Op6besel) <br /> stest. zip 14 (-C1,6 <br /> ,ilingAddirstansCIty <br /> 3AFORATIONA-- I�........... 1`1 P.,,,ownswip 0 LocYA"mcrrll COuNTy Aaea.-r❑ �S7..re�A�_O�FGO ADENO OTHFRU <br /> FACILITY FILE <br /> WITai <br /> N!. <br /> )ACIPLETETHEFO'LlOWING BUSINESS I FACILITY I SITE INFORMATION.' ye, No 0 <br /> this a NEW IlLexinetas Lo"Tiom not previously ragwated by the&-tRQ,6WGWA&.HEALTH Onnstoo 7 YES O Na a <br /> this an E:KISMNG Busines,is LOCATION buts New TYPE Of ftgulat"d Buri naez`7 <br /> Lisnoilsslizamiu"ISITE NAME <br /> BLVD=$PHONE <br /> Ins ADDRESS VIA- <br /> IQ <br /> I STATE ZIP <br /> 5rry <br /> 5i <br /> I <br /> 2, <br /> MEN? <br /> Attention: Carol Of(000nwl) <br /> Railing Addreas if0fPFjFR4FNT ftffl F201154Y AdWte� <br /> STATE 4 2jP <br /> Baling Addles.:City <br /> ::@�==gq <br /> . ......... <br /> M <br /> 2FAM,�n &M I <br /> mar MINE <br /> HIRD PARTY BILLING—ImFoRmAmcm: Complete if Billing Party is rentfroInBusiness owner identified above. <br /> --------—- <br /> Attention:oroccne Of (00conaQ <br /> BUSINESS NAME <br /> fA, <br /> m,eftng Addreas 0 fs <br /> ATHeSF7(, 7j? <br /> CITY Hous.*-Ew-� ST <br /> THIRD PARTY BILLING <br /> for fees and charges OWNER FACILITY113LISINE is Bwia,zz,and I Isime-1c4ge that A <br /> ALL14C AND COMPLIANCE Afl,�OWLIZDMXMI yr <br /> ,EpMr FZES, pl;N.iLITFX.FvloficrAffAT Cm"GES and/or HooUr QURGES associated With this operation T40 be billed W am at the address Identified abase at the Acca <br /> , is true and 40�t; and hat all � <br /> I Qnft for this site I a" .rdly,hat all information provided on this Appli,;slio . 121,d 3ctp4tias will be Wonncd in a=urdaaw with all <br /> pplicabje SAN JoAQuO4 Cou,4Ty Ortlinucts Codes aecifor Standards and STATI and/or FcoeRAL La"and Regulations. Aj the indmilsecd -,oem. J QVLN Cot;ape�zer,m neat ofthc property <br /> 'I. to S , <br /> o,zM,i ac the abover�jjjryjojw sdd� I hereby authorize the rolo�a or any and all rewdu and oniamoo,951 maossenent i1sro"zo SAN CA COUNTY <br /> '-,XVIRONMENTAL RM ALT DIVISION Oawn.it is available and u the same time iL4pmdedwme amympmeald,e <br /> PLEASE PRINT <br /> APPLICANT NAME SIGNATU <br /> Gil DRIVER'S LICENSE A <br /> TITLE Qg4�0'a' fpHnTn�np,r grpi ifny <br />