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04/24/2003 10:37 2094683433 FIFTH FLOOR PAGE 03 :»� •»,'. uln�»�""".,:'S'»:�A&"�iY. <..w. rrv.v>. '.gee'vrC'r"^.»"P'i:'ii:h':;Sti�Y'eewa•-n>t•'+.:..X�( ZC' +ism.3:::1G�-`•i,�w,�%��'�:':°r:•w».iayw�:i�:1+r MOR 9. '�°°.t-Rsr,+t°d::e•:.'va�,!.p?:p€ err FORM (£Hwi5lRews40t16r1tf9T) DATE MASTER FILE RECORD INFORMATION ,1 $r"vr i rrw 4'iii +kr° ": Ir 4 t,R•. i ,.f. #*' UNIT I V 1 »1 L. ii'fr`.:.�� ' ��i�:; p�!f ,3.•:;�`<'<'".A,r 'sf. <s":«r':`.>,��n` :i . .- • QWNrzR, FII,k COMPLETE THE FOLLOWING BUSINESS OWNER /NFORWWON: Cl+Ecrerc OWNER cuaa trrtroNFlLswlrHt:�n ❑ .....,............._......__; _ _ . . P ... . . .» . _—_._ »..»»». ..» SUSINSSS Rich •/T�Q1�+r1�'� " �l C � 1 i OWNORNAME L-------- r- --- e ..'t3t1S1NESS NAN6(If diRbrertd fiornOvvner Natrte).............»........�!....._'/...`.............� t OWNER HOPEADOAESS � 7f� E ORMER'SLICENSE# city SQC�GrI�Lv! STATH i ZJP SS6Y 5 OWNER MNUNG ADORE3S (ifOIFFERENT h wrr owner AddrsssJ Attention_trt Csre of(optiorrelJ i Mailing Addr—City Stats - Zile CORPORATION/W INDIVIDUAL. PARTNERSMP CI LOCAL AGENCY COUNTY AGENCY STATE AGENCY Cl FED A6ENc r O-trtER� FACILITY FILE x"�d;x.?��s$;8�: .� td�fk� ,. iu C0mptFTE7-HEFou gWtNc BUSINESS I FACILITY I SITE IMFORINATIDN: 1-,this a NEW Buslne]s LOCATION not previously regulated try the ENVIRONMENTAL MEALTIi 0WISMIM 1 YES Q NO Q Iv thG Cl NO an EAsnNG etisim"a LDCAttora but a NEW TYPE Of regulated gU9iness? ' I 8U31NE33/FAGIUTYf$fTE t'lAlA[: ' Be;31NE33 PHONE SITE ADDRE53 r STATEZ]P ' Gm °'•Y.Ci'S, '...5 •g}r .l tS.`sc t, tn>v -<v.t,k<c.>o,...;. v;l' ••ti �G r� >i wott:a ':s o t F Sp, .� kt' Sl'. ,y,4s+x�e 4Q �i SSWf�git� $�..� Y.�L ' ��/h.al: Y• '{i• .�Sbr.'1Ti`i<« :.S-:�`rla*�`S..i t Mailing Addreas.r OrFFERENTrtarrt faei/Yy iiddrrss -�/ tt»ntion:or Care Of(oPtlen�r STATE 21P / tl/� / t Mailing Add3res3 City / h // f1i1 '� `^� -£iYS Jlrttl3ns _I' �4 ' d;S ;S�G.t �«I ''`�•<.t": `:s?YtiF;y F��"'r'�'•. .•_' 4' r'x� t•�.w 'd:I.:;,:'f�•f1-4 ..,c,,.�� . ' THIRD PARTY BILLING 1NFORMA-1ION• COM tete if Billing Party is differentf'arn Business Owner Identified above. BUSINESs NnlvE !j 165 a J vc I'4SSe t. C 1 Atlee tion:orX�ef /i Y eG`! c �Q� Y / ^ PHONE Mailfrtg Address ./r7 P� S�l yv� CITY 3 7 6C f vt r STATE F ZJP f z 1b.4 Aq,= for fees and charges OWNER FACLJTYIBUSINESS TH RE;PARTY BILLING f3tLLry ,lYn CoNpt.t�YG£ACI.?JOWI.YDCME:7T: 1.the updarsigned applicant,certify tlut I=the Owner,Operator.or.-tuthorced Agent of this Business,and I itbw*ledge that all Pe&Vl'r FESS,PEKIL27M ENT0RCZV9VT CAwtrtees and/or HOLMY ClrAWZS avociated with this uperttivtt -ill Ix billed to me at the addnttts identified above as the ArrQ4t rT 4DDRE:SS for this Site. I also certify that all informadan provided on thh application IS true and correct; and that all regulated activities gill be performed ut ac'yrdancc v"h a!1 applicable SAtt JOAq%;LY Cot1,`w Ordinance Codes and/or Standards and STATG and/or Floep—%L Luxs and Regulations. As the undersigned owner,operator,nr agent of the Property oeated st the mbove facilityhita addre>is. I har4by authorca the ml[o o or rano and all r ultt end anvronmental asteswnent inrorrnsnpn to SAN JoAj:QUIN COUNTY ENVIRONMENTAL HXALM DIVISION as soon u it is av-,dlabia and at the same time it;a provided tome or ety reprtlenmlive. / Pt.ZASE PRINT SIGNATURE 77 APPLICANT NAME l�U ,L��rYrC� DRIVERS LICENSE I: 403 2 Y 170 TIYLE �.JitRwddG+d`s1if�.�ib��`(`��i�.a v:fTate-3�*�"' �� '#w"�3`�•st t� r ,��+snt6ts9t]EfFae�r�e�a4�;: •tXt?...�sr...K. :i'....?F..ni .. ¢*J .r'�:.e��a