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S-21-1998 2:a5PM FROM P. a
<br /> No M .. c�91 !r!„� 8a ��, t1
<br /> GREEN FORM
<br /> DATE IL QS MASTER FILE RECORD INFORMATION "MFR"
<br /> gygµlfn�NF�FON fHD LI@E O�IJ y UNIT IV
<br /> OWNER FILE
<br /> COMPLETE THE FOL LOWING PROPERTY OWNER INFORMATION.' CHEcKiF OWNER C4VRRCN77rowF/cEw[rHEHD
<br /> PROPERTY 1 PHONE //��
<br /> OWNER NAME S V
<br /> I S 9 3 - o-4
<br /> FrN ,,NI ll.V
<br /> BUSINESS NAME S _T H $-: L>Q N � /�SCJ M P rj N` Soc SEC I TAx ID#
<br /> Owner Home Address DRIVER'S LICENSE#
<br /> City STATE ZIP
<br /> Ownor Marling Adds" I F u-17-
<br /> Mailing
<br /> Mailing Address City 4, , ry r' State Zip
<br /> CORPORATION INDIVIDUAL D PARTNERSHIP❑ FED AGENCY 0 OTHER O
<br /> FACILITY FILE
<br /> ��._Ac L .,b. w' , r.�rc .1' �sY. ,. „li ��I•�;�,IF 11.°� .� I.�' I�',�,+rl r.i-!a�'.::,!r „�
<br /> COMPLETETHEFOLLOWING BUSINESS/FACILITY I SITE INFORMA770N.
<br /> IS this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DIVISION? YES 0 NO 2,
<br /> Is this an EXISTING Business LOCATION but a NEW TYPE of regulated Business? YES ❑ NO IQ
<br /> BUSINESSIFACIUTY/$ITE NAME
<br /> SITE ADDRESS I ! O so D74 �jc I AV F_N U k SUITE# BUSINESS PHONE
<br /> CrrY 1 �T, ' ^O n CA
<br /> STATE ZIP 9 �� O
<br /> ,�,,7;19 u'r"RT' _.,` lL`F';^'?V`.- rTn•�,vlry (,,>.., `.„�: 1 )..,a ,;I'�'ty'M�(�'ti.'f,?7,I_yPl!f?''4�nc'Ir1s'�' .I•�. �i`7f/f-lr,. i.�.;.
<br /> '-�^" Avh 1 v�1t iT,{{r$ � r n� -��1�1_•J W ,.fir p a�I!•! yy mri+ I.� NFawrrrlAlyIRl:, �•If�u't ar45.t lyw wt.`'�.._�Ir Ilta'�7n r,t;`.1'I I t�!r. +
<br /> yy�� ��
<br /> P 71
<br /> ,��'t1AY as �._.._y__'z _> Pl` _ .:` ....,..�J,+c�14r!It.l�u.,. I...l.�..._.:x_.__l.._.,.,, _" ._._ .....tu ?;,�L.6�iS ,.•�.,�.W. �.�.__
<br /> Mailirg Address ilDIFFERENT from FecilityAddress Attention: or Care Of(optional)
<br /> F a af,iLA-P�
<br /> Mailing Address City L4 �'1 —� S7— ^n�/ L�^r 6 STA T>i , ZIP
<br /> T K'. �,awr lL I,et, c'V 'J TV`
<br /> YJTY
<br /> ?' ', a 1 �, t'1 a .YJ ...^ '' ti. rF'�.11 �t ' iI r>wl .y1.r�, I it�r,_•.ApI 3. , f' , tl .t y.
<br /> AF'el �,P �r. 'rr'tr �$ n ti.. �,'t t R :es;
<br /> THIRD PARTY BILLING INFO: Complete if Billing Party is different from Property Owner orFacility Operator Identified above.
<br /> BUSINESS NAMEI Attention:orCare Of (optional)
<br /> l C_ Q
<br /> Mailing Address 2�' A A I r, 1 CT !\1J I;C.� PHONE
<br /> CITY n\ �"(�Z I V c_(_S C I �. $TATE ZIP
<br /> .9e=qAr_9DDREss for fees and charges OWNER FACILITY/BUSINESS THIRD PARTY BILLING
<br /> BILLING AND COMPLIANCE ACKNOwLEDC%ICNT: 1,the undersigned Applk"t,certify that 1 am the Owner.Operator,or Authorhed Agent of chis Business,and I acknowledge tha,311
<br /> ArwfrrFEEJ',PENALTIES,ENFURCEmEVT(71ARGES and/or HoU)l.YCHARrF_T associated with this operation will br billud to me at the address identified above at the Aocy)yNrAUARfSS
<br /> for this sire. 1 also certify that all information provided on this application is tnlc and corrsct;and that all regulated activities will be performed in accordance with 31:applielhk SAN
<br /> JoAQVIN COUNTY Ordinance Codes and/or Standards and STATE And/or FEDERAL I.Aws and Rcguiations. As the undersigned owner,operator,or armt of the property located at the
<br /> above faeiliiyisitc address. 1 hereby authorize she release of any and 311 results and environmental assessment Information to SAN SOAQVIN COVNTY ENVIRONIMENiAL
<br /> TIE.%LTH DIVISION as soon as it is available and At the same time it is provided to me or any repraaentative_
<br /> PLEASE PRINT
<br /> APPLICANT NAME l �C)��F. SIGNATURE
<br /> TITLE DRIVER'S LICE #
<br /> "PilomcoPY REOJIR£al
<br /> t I� •ryQ ..yiL fid, t';x/_,P k 'P ay,r py .. ... Y ry'�^'• ,r;V1,.r i^,'1'1 .li'�rll k ►y1 y
<br /> p=47d
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