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77 <br /> oun telt n 1 a tett Dlv 10 <br /> tEH no 151REV,eCP OT,4Ai'i? <br /> - <br /> DATE OZ 'd { ^ Q I MASTER FILE RECORD INFORMATION FORM <br /> :nureeeauisna END,tiE Q+o UNIT IV <br /> BW f�Dp99o7`� OWNER FILE <br /> ..,7RfPLE7>'TNEFt)LLOW/NG BUSINESS OWNER 1NMRMATloN.- CNeoxIP OWNER Cuaat v Lr oNrrcrw txEHp <br /> _,._, u,..... _.._...___ ... _ ...,,..._ .,,,..,., _.... .....................M.. - -- ...._.__....—...---.........................-•-..... <br /> f?IVmiiRN <br /> yRNAME ------ --------------------- -a }a <br /> z <br /> LISINISS NAME(If diftwnt ham Owner Narne) Sob 5E6/TA><tO i1 <br /> AYNER HOME ADOREsa 2 ( f ( 6 � 1 _ �(C.�. { DRrvER's LrcENeEX^N...—. 4_^,•. <br /> t lva - sj \ ! smears A rip c�C3 <br /> '.'vrx4a alAtuNG Ap6aEee (!f Dl rom OtmerAddressj Attention: orCam of (opil� onal) `— <br /> ._ . ............... _... <br /> rutting Address Cityr C9.h . 1 O Y.-. ` state Zip <br /> *!RAPORAY16N1] INOINDUA). PARTNERSHIP❑ LOCAL ADE E3 COUNTYAaENCV❑ STATEAt6b'Hce0 FED AcCNCT❑ CFHERC <br /> OG /q 7 FACILITY FILE <br /> %49,*LETETNEF_OLLOWING BUSINESS/FACILITY I SITE INFORMATION: <br /> s V3 a NEW SUsinesa L6cAnON not previoualy regulated by the ENVIROHMOCTAL HEALTH 01ASION 7 YE! [J _ No W. _. <br /> c Olson PxlsnNa Business LocAnON but a NEw TYPE of regulated Business 7 YES ❑ No ) <br /> JSIh2siJFACIUTYMrrE NAME , <br /> re.ADomss - ! sun:tl 1 BUSINESS PHONE <br /> STAIIE r IJP J `� <br /> t <br /> ',tailing Address jfDIFFERENrlhdm Fac!!ltyAddress Attention:or Care Of(op8onslj <br /> .•amny Address City STA zip <br /> Ni,i - PARTY BILLING INFORMATION; Cplrrpl@t9!!`glllin Pa isdlJferentb•omBusiness Owner lden-ifle <br /> e <br /> I <br /> ?.fkNess NAME <br /> F Attention;ar Care Of (OpOo af) <br /> •A,iing Address a PHONE <br /> r i STAT7; :` zip <br /> _ .zs for fees and char es OWNER FAGIUTY18USINESS THIRD PARTY BILLING <br /> _,twG AND CoatrtJAI:CC ACJOtOWL$�G,\{pJt'tS L the undenlgned Applftast mrti�that t am the Ownr,Op&m'or,or-dNehPrhul Apev afthis Business,:nil t arknoM•Itttge Viae <br /> ;-14"T rfUPEVAL770.ENF0RC9HEATCIUAGfS Andror hrOvxty CNAK&auociated with W1 operation will be billed to me At the sddreu{endued above as the ACC. _4L7+Y,Ufdry,. <br /> 'Nu site I also certify that all mrormedon provided da Chia ApptiatiOn b QMe and mrmx and tbat all requtated scdvjtW will be performed In aecorc!A c with all►ppRobto.4,�.• <br /> :?UCN COVKIV Ordinance Code aoelfor Siapda}dd And Sun sed/or M MAL taws and Royuladom. As the undersigned owoer•owrotor,or Astor of the property located at ri, <br /> "t fa-iii"'/site address. t heeaby authorize the rvbc c or any and all matt,and eovi"amental Attnttaapt ioformption to BAN]OAQL-W COLrfYIY EM'IRONAIFN7,l. <br /> .',LTH DIVISION As A000 as It b»ailabte and At the same time it is provided to me or my reprt nudve. <br /> PLEASE PICHT <br /> w?LICANT NAME w _ I t� . Q _ .ILA i, / SIGNATl1RE ` <br /> JI¢ ,LJR-.I IAV IA <br /> DRryER'S uc SE a <br /> oa eau eted: _ 'Dal . �.jj <br />