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L)6A1'-1 FROM „fin <br /> OWN <br /> DATE 1 ...,.. ....... <br /> �'��l MASTER FILE RECORD INFORMATION "Ifflip" GREEN FORM <br /> SML-f1 L4E�6 E�GW(t��►QN`Y /. '�� <br /> OWNER FY N I ■ 'V <br /> CO19PLE7FTHEFOCLOW/NGPROPERTY OWNER INFORAfA7xpN, "— GfrFt+crt OWNER CuRxE,vrcYON FILE wrrx'cND <br /> PROPERTY <br /> OWNER NAME PHONE <br /> BUSINESS NAME <br /> N,,ja ( lomrnurli cafirr, SOCSECITAXIDO <br /> Owner Home Address <br /> DRIVER'S LICENSE# <br /> city <br /> STATE zip <br /> Owner YWIInq Addrop 30 5 -Vy F-Ce )Ave nil° la c—Y 3 <br /> R6,) I-, q r-d RQG <br /> Mailing AddressCity 'S O SCate I/ zip 95 0 <br /> l� 3 <br /> ORPORATION❑ INDIVIDUAL❑ PARTNERSHIP❑ <br /> D FED AGE»CY onIER C <br /> FACIUTY FILE <br /> COATLETE rHEFOUOWING BUSINESS J FACILITY!SITE IN <br /> f=oRAa noN; <br /> Is this a NEw Boniness LOOATjCW not previously regulated by the ENVIROOMENCAL HEALTH D#miciN? <br /> YES p No <br /> is this an E7t15T)NG Business LOCATgN but a NEvv True of regulated Business T <br /> YES O Np <br /> BUSINESSJFACILITV/SITE NAME <br /> SITE A'JDRESs <br /> SUITE X BUSINESS PHONE <br /> _. Urn O�irPN �i✓e �.0 na S 100y $ /06 <br /> CITY 5� A-IV4 STATE j!P p <br /> =_-�^x + ::135 �an r awgKti rw t grf7ra L- x /Sp?03 <br /> r,rv�h <br /> . ���_-�1 5L�� � �� )I ,,,�• n. <br /> Mailing Address IfOIFFEl7ENTfi onr Fe <br /> ciNyAddress <br /> Attention:or Care Of(oplronal) <br /> Mailing Address City <br /> STATE LP <br /> 1 <br /> , <br /> TmiRa <br /> PARTY BlL1,IW.. .+v +, <br /> G INFO: ComPm f Billi Party is ntfromP <br /> OUBtNESS NAME roperty Owner orFacility operator Identlfedabove, <br /> �/ —1-- /� / <br /> —re-b-4 -/P L'LI y i7 c. Attention:orCare of (aptim_kW) /� 3en i761a <br /> cm <br /> Mailing Address i0( . 0 <br /> N• Rost'AV Bl V PHOH�626 <br /> STATE �I q 75P9/�O <br /> Accauy>•,dnnaE5t8 for fees and charges OWNER 1 <br /> FAGUTYBUSINESS THIRD PARTY BILLING <br /> BILLING AND'COMPLIANCE ACWNOW LRIW..Mr!Nr; 1,!AE onderw'gntal Applicaat certifv Z=1.711 Gwncr,Oprrator,orArsrhori;.d Ayenf of this$Ugittesy and I xclnowl <br /> ilrRmir r6FS.PEN4L77"ENF(AKEWAN7'CHAX(:ECsnd/or HrXfx►y Cl/ARt;tsS associated with this atiol,&n will �Hutt al) <br /> for this site I alio certify that all information provided on this apPIksttoa If trvt and corset:aid that all ��actiY.1 at the peri ss cd in c ordanamwe a the lAll�Applicaw AN <br /> 30.10DIN COUNW Ordinance Codes sad/or Standards Said STATE aadbr FinanAL LMM anti + �I d e WIN er FeIfmtor. ID accordance of the prop trt,loc tm sit <br /> gay <br /> above facil) Mite addrwa, 1 hereby authorize the releate or arty and all resins and eavtro�menUeaic0, 4,the mtdersipned n o S oN JOA.or Sarni of the pralCerep t<,c.h,d,�t fhe <br /> HEALTH DIVISION a$wOn as it is available and at the wale thie it is ,tesameat informStioa to SAS Jf>AQT RN t:()t rT y lE VV�a20NMLY1':�t. <br /> �+Oridetl 16 me or W're�ceaesrtrtiv.. <br /> PLEASE PRINT <br /> APP'IJCANT NAME H Po,*N M 1 2 p I� SIGNATURE ' <br /> CC4. D <br /> TITLE r01a n 6L 6 DRIVER'S LICENSE.0 <br /> NTW <br /> 'aW ++r�.� '. xi.�Gr,+M�� 5.'J.: rltil, ,, .IQT+t� ' fj •,; l�.y� .. <br />