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07/20/2006 22:18 9256856768 HULTGREN-TILLIq ENG PAGE 02 <br /> Sz aaquin County Environmental Hex- j Department <br /> DA-M GREEN FORM <br /> M <br /> MASTER FILE RECORD INFORMAJYON "MFRS. <br /> gtanncn e�•enc E1;1iLU�MLQmt <br /> AI ,r <br /> r l'I '?y'I�f ip7 M�� �� sjsA�Mt��iG;��ii �j Iklii llk�'rri ftl'ttl it �akt{ nlwJ�p�'r \\�� Y <br /> i.vI nD ��1�,,4u <br /> OWNER FILE <br /> CAMPl�7PTF>r£Ii�[LOwING <br /> r-011vnWN INt kmv:mm,- CWOCIP OWNER t JYayUdvnt--wXW E"V <br /> PtrW'EFiTY OurNLk' NAME <br /> rS 1 r{t r�� <br /> V v i -�D v E C, . )o i- `/�S- <br /> Flrst MI <br /> Lott <br /> BUSINESS NAM _ <br /> U 1 ��-� .�• �(c�( ��r I SocSr-c/TAX iD# <br /> Owner Horne Attdt ess <br /> �y-7 <br /> l� 4 <br /> City al, `n/-1L <br /> (� <br /> Owner Mf allingAddi <br /> Mailing Address Gty ZP <br /> COPPORATMN❑ Imijim AL❑ pAIZMM m IJ �t <br /> �■ C fitn A6HtCY LJ Qitq±ti <br /> Ii''ryF AC1 TY flIX� I :y, � ' W- 551,' <br /> 9 �ii .J <br /> Is this a NLIAI Business Loarrmry not prteYrousiy regt,labed by the ENMOkMWrAL HEALTH bEPAR7N W" Yes © No �A1/e 1B L k <br /> Is this an DnSFMG Business l ocATioN but a Ncw I""of regulated 8u{iness7 YES ❑ No <br /> Jn/StrE N+u� <br /> SM ADaRess <br /> Smm At BttlUAM PHONE <br /> QTY <br /> STATE ZIP <br /> IN <br /> 011 <br /> 97 <br /> t�ui'I I ! <br /> Making Address jf'P r,(mm/�i <br /> ' 'Emw At 1attUm;cit care of(opdScvvo <br /> Mailing Address pty <br /> STATE jpp <br /> raHlatlto PAarY 131LUNe INaoy Complete If Burin Pa Is dl�reJ7t cram <br /> 9 �Y Property Owner a Fcillty Operator ldentiTied above <br /> Susumss IVAr+r An radon:orC ra Of(opgprra/ <br /> Mailing Address <br /> crry <br /> for fees and chargQs <br /> OWNER FAciLiTy8uslNEs 9 THIRD PARTY BILL m <br /> r terAND('Oafer_aAnrraArKu �.DMIw_• ar �waaaai_ttt <br /> �u 4 the undetgiguedC12 App6wntI certify that t am the Owaa OfiOmNr,or Au1Jwriz!l.gear of this RtWacm,and i Acknowledge tltlt All PrRM1r FEZS, <br /> zn�u rrEs,ENFtwcrrrrnTCtuRces wdlor({ornurChyRGES4 L led with th operation will he billed to most the addrees ideal hied above As the <br /> Informatinn provided on this applkltinn Is true and Cet'a'ecti Land that all re"ilAied actrvitles will be�o is accordan¢with all ayplicnble SANJOAQUIN C6vNW Ordinarice Codes and/or <br /> for thissites 14-1.10 cerdry that <br /> AOWLMT <br /> a.dards And STATE and/or t�IP-0PRAL r•avvs and Rglvlatfoaa As the andersi�ed esTnor,operator,or a <br /> y and All re R3 And onviranmental Asse!L%mcat Inlbrmation to SAN JOAQUIN COUNTY ENViRONMENtn HEALTH D1PAR C above far,7ityJaite addrpg I hereby AuthorinlAe tcicascof <br /> ovldod to moor my representative• _�soon Aa it is available and at he same time it is <br /> XPPLLCANT NAME �+, P Ptt7trr <br /> r r-✓-S �G[L G tC' -_ SIGNATURE <br /> UTLE�i^/n c i • -i �/i ,if e4l_— "•—•` bR1VERa <br /> ^S Ll wse# <br /> f UIRED) <br /> WPtvvcd 8y OaOa /Iacamgn0 tXfrca p <br />