Laserfiche WebLink
12/.17/2004 15:39 209468P 33 FIFTH FLOOR PAGE 02 <br /> bau <br /> GREEN FORM <br /> DATE MASTER FILE RECORD INFORMATION t`MM" <br /> UNIT IV <br /> Pt?IA71aa OWNER FILE <br /> I CHAWIF OWNER CVAI?E�YONnLE�EHD <br /> COMPLE77 THE QATNGPROPE OWNER INFORMATION: <br /> PROPERTY OWNER PHONE <br /> NAME <br /> Firs? W1 fast <br /> BUSINESS NAME jqe9e ^f Wtbel- Z-L C SocSes;/TAx IDV 41qo q <br /> owner Nome Adele DfUnJEWS LIaNSE# <br /> City STAN zip <br /> 0,eoier Ur,.:verx-,4,i Avenue- <br /> Mailing Address City state ap 6>2S <br /> .5*4 C/-a W%-C-+-0 aT <br /> rY.osr.R.nnN f7 0 El <br /> CLIMPLEM WEMLOWNG BUSINESS I FACTI nY f SXEF rwojimmxog- <br /> Is this a Nm Business Loanors not previously regulated by the ENVIRONMENTAL HE DEPARTMENT? YES MI F-1 <br /> No <br /> Is this an E�NO Business LOW ION but a Ns:leTYK Of regulated Business 7 Yes NO <br /> )&USPWSsjFAwjSM -r, <br /> NAME , 7" <br /> SrrE"'U'l/cSum# BUSINESS PHONE <br /> c17e 9rATf ZXP <br /> '�17 '7k �7'7;I-7 <br /> Mailing Address if D.FFfExENrftm Fv Wfy Aed5,vacer AttentionWr Cam Of(Optirkarral) <br /> -7 <br /> S�IATF. <br /> Mailing Adds City A.:t/01-r:;;77 ✓ 010- (1,,4 ,4r 71P 15, 9"Z5 <br /> sic ....... <br /> THIRD PARTY BILLING INFO: Complete dBilling Party is different from Property Owner or Facility Operator identified above. <br /> BUSSNESS NAME / (opt <br /> OrCave izzaal) <br /> W(Af (,ic, - i ASfvc:-4cj Attention: I - — l � <br /> Mailing AdAddressPWME q) 3 7 2, q.3 <br /> WAVE 71P <br /> c" IA)e) f- <br /> AC=9WAQQ9zKS for fees and charges OWNER FACILITYIBUSINESS THIRD PARTY BILLING <br /> All/,Nn kNr,romer rAyry ArKNOW1 1hr.41ENT; 1,the undersigned Applicant.ccrdfy that I am the Avner,Operator,or Awhorl.,d A,,rt,f this Busive.,and I acknowledge that 211 F-XIflrFXEs, <br /> PZMLT1z:rI EXMRC usicw CHARGES gncVgr HOMLrCguecC 2,seciAted with this operadon will be billed to me at the Address illtntiraed aboyC 34 tile AcCrInAnoaffr for this SIM- I also=rtiN that all <br /> ieformadoes provided on this sipplistion Is true And corrccr,and that III 1`0e1111"2cliVifi(ll will be Perror.cIll in accordance with all .,pH=b1e S.w JOAOCIN COU. Ordinance Codes.."r <br /> Standards and STATE and/or FEOERAL Laws and ReeUladona. As the grWersigned owneq operator,or agent of the property located at the abc,,ic facility/.it.address,I hereby..1horLe:the release of <br /> any and all rnsuli;and..Aroaracrital assessment informIdon X.SAN JOAQLJIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it Is available aM at the same chat It Is <br /> provided to soc or rn,repstsentafive, <br /> PIrASE PW Nr �. <br /> APPLICANT NAME M ej SIGNATURE <br /> TrrLE j (tenfe C, f <br /> 13P"ERIS LICENSE 9 <br />