Laserfiche WebLink
;:Sgrr�oa�gwn�Guun,� P��bficC_Heal#_h^Services i Erf�ir�unfr�p�'.Health Qivlslon _ _: <br /> GREEN FORM <br /> DATE MASTER FILE RECORD INFORMATION "MFR" 1 <br /> SaAoro Aetux•Oe EMD uaEOnr UNIT <br /> IV <br /> t <br /> OWNER FILE <br /> COMPLETE THEFOLLOWING PROPERTY OWNER /NFORIwanON: CNCc F OWNER rusor nr4WFr ar;W EHO <br /> >ROPIJITY �i /'Q�\D �rIS jRI.G�bN � HOME <br /> Yt IA AR <br /> aus..G"NAME 7=0a4) C�j /`I p ANY I Soo Sao I TAA IDR <br /> ( I <br /> Owner Home Address DRIVER'SLlcarsEa <br /> City STATE Lv <br /> ow..,Mw;.wA.er... 63c2 -�. LOC1��TaRO ST, <br /> Mailing Address CRY `0>7( slatsG!}' zip <br /> CORPwA"F ft wlotuu.'1 PARTNERSHIP PEO AGENCYI� OTHER, <br /> FACILITY FILE - - <br /> -- FAZ9WTsqw.'� 7 .�'. � CR039�lREFlfb . :�...,r _,__. .'yO�GCOfA¢�.1iFiR.`. _..mss...:. '�-.:.Ju.dl---•....-.__.._.. _...___._...... <br /> COMPLETE rHEFOLLOWING BUSINESS/FACILITY! SITE /NFORaunoty. <br /> Is trdn a NEW Businasa LDCATiOM not tlreviaualy,regulated oy the I!NVIROMREMTAL HEALTH DIVISION? TGt ] NO <br /> Is this an EAtsrING Sushseas Loc n"but a NEW TYPE of regulated Gusin ? TES I] No ❑ <br /> BU&HESGIFACXLITTISIIT NAME TO Q'> CQn15-(']Q''C rT-10�"/ �1 U M /2 A")/ ITIS rip <br /> SITEADDRESS l e O L�6 /�. 1�/G/. _LO T�NT'TGL Sul�vfla33P�lll/ <br /> STATE -�/Zip +O <br /> Malting Address irOIFFERENTfrom Fscillly Address Attention:or Care Of(option) <br /> 63°1 �, LGc�rOQ� SI l�ii2lr— JONES <br /> Mailing Addroaa City LG a7I STATE C'L� ZIP <br /> is .__. ._.,•R <br /> .APN711, bL?$ :�Gl'Ct t-(( - <br /> THIRD PARTY BILLING INFO- Ccu"PteI6if Billing Party issdifferent from Property Owner orFacility Operator idendBedabove. <br /> SUSIRESSNAME 6R0v,4D zZAQ) Ar11AILy5LS r irJC_. Attention:or Care Of (options) <br /> { ;20 g3 S' —Q 1'rMailing Address l . g' <br /> Cnv L S C.A}L Q STATFGA ZIP <br /> /ICCOIINTAODRESS for fees and charges OWNER FAGL!?YBUSiNess THIRD PARTY BILLING <br /> 31LL1!!O AND COMeuA4rr.�QOI0WLL9CMCVY: 1,she underaiped AppI;".t,c,.ti&that I.tit()f.ao.OFomar,or duerom.,rd ApCd nr tM5 Raaivela,and L achnowled-c that all <br /> PrAVar F=➢cvunAe%ry otryt¢vre„yt:e zad.cr HoVaAri.Mn%Associated with this operaoon.n5 be b lcd to groat she Addris identified aeove as tAe ACVM nTADDx6s <br /> for mi sitz: I atm mr ify that W iafonsader,provided on this RppMcation is true and tornecC and that aft regulatel ecdvidts wDl be performed in AtOordaace T se 211 Ap Bubb SA, <br /> JOAoum CDulm 0MnaaR Cocits andlor Srnndal'd1 add STATE AA WOr nDERAL LAM Amt RsA IetlanS At th¢undettpnld aa'n:f.opernttr.ur Ment 0(MIA propney Mcatad at:be <br /> aoove faNi7hae addrev. 1 hereby aathorve the beau or any and Ae rosutts and evvirOnmenbl aswsimeat informatioa�^�AM in.IQ tv CQUN'TY ENt'IROVi1E�TaL <br /> H FILTH DIF1510\r rnotl as tt M avaiurde AW a[fM ams t®t R M prosided to vA:w my npraaARntwA / <br /> PLGAx PmreT �I <br /> APPLICANT NAME G P`7Gtr'C� -roto AFrAt.Y S IS SIGNATURE/ ,� v <br /> TITLE ,5'GL c6GR� /'. Sii-'/j vCCE (,�2<� DRIVER'S LICENSER <br /> -l-toracoPv RroulReol <br /> -Appre4led}RY+.r. z-17.;Gca -Da .:r=� sAeeouttting Office Procaealydreb!rpteead - <br /> 9Y:_ <br />