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DAZE ^� �b06i 10:15 20946634wY w PAGE 02 <br /> EHD <br /> 11i11Gtdl . . , r <br /> MASTER FILE RECORD INF'ORMATlON "MFR" GREEN FORM <br /> dYdIIeem A r 1 <br /> �o�� i owt+eeFa� UNIT IV <br /> COMPL T EPoLLOLt? GP OPER OWN <br /> PR N <br /> PROPEATyovREA MA ONL <br /> OJeaTry OWNER LUnrtEwnYONFJiF tP+TNBHD <br /> NAME <br /> PHONE <br /> Fvsr MI <br /> BUANESSNAME 1 tea <br /> Owner Nome AddreW SOCSEc/TAx IO# <br /> 2 <br /> trey <br /> A ,,. 1_ -�f?-• DaNEris -----------A' <br /> Owner Mailing Address 4" np <br /> Mailing Address City <br /> lace zip <br /> r"oannahnw❑ NnMNUe.❑ <br /> Depe„apWro❑ <br /> DI117�og <br /> LYn ee [I <br /> IsthLsaNnwSuglnbssLociTTON � � <br /> not previously reguia <br /> tedb'/the EtmRENMaNrAL MEFLTM DEPARTMENTd <br /> rs this an E)DSRNe Business LotwrroN 6uta NeWTypa of reyNated Bualness Z <br /> Yes ❑ ��. <br /> BVSAe6S/FAQLIIY/SIiLNAME �. . YES ❑ <br /> No <br /> SxrFAooness � A a <br /> CRY 14 1 CO ck Su BUSINESS PNONe <br /> srATR nP <br /> MallingseIfD <br /> gddre 'FfE,wNrh J7Irad14A0'&e,, II <br /> Atbentlon:or care Of(opt/onarJ li <br /> Mailing Address City <br /> STATE 7jp <br /> A � � <br />"'RD PARTY BILLING iNFOr Comp/cif Billing Party /s di/feregtirom pro e <br /> lusrNEss NAMa P 1'ty owner or Facility Operttor <br /> C ✓•u" S F- irc nercTreOf (apt/oidnean!)t <br /> ifredabove, <br /> Iallfngtldd,Ess <br /> m'`-\1 <br /> 'VM f1K LS ��QODCIO� <br /> STATE c A ZIP ,r <br /> .B�Sf for fees andchargeq OWNER <br /> FAGLITY/@USINESS THIRDpgRTY 61LLINp <br /> L7J4. NAM,. a,the Undersigned Appiloam,ocrdly that I am the Oa"0.. <br /> Operabq or ANlhorlud <br /> ilvrc,� '��/E/'rCHAAodTand/or ArMlr CYARGIt <br /> radon provided an ads Applies Is train and earree5 andthat All reed lad a"will bc ities billed to ank Athe address idendned boyo at the ba,IrNte.and I acfar this sit that all Pexurr6arg <br /> lards and STATg andro,lraDgp "uu Iss and a al C] iom. At the t All r"N,cd owner,o re r0f this site. ]also,ertiry]Nat ag <br /> end an reaWls and enWronmuilar La,,and fararmodan to SAN JOA Performee in aceordanw with <br /> w1 appllcablo 3nN TaAQmN COUNTY ONNpace Cedes and/or <br /> ledl� Ny or agent of rho property located h the eboya tecfdyhilc addross,L hemby"th'"Ce the e'a na or <br /> ad to ma or aW r to 1,amen, QUIN COUNTY ENVIRONMBNTAL HEALTH DEPARTMENT as Iron as it Is Ivan <br /> able and at the samo time It L <br />'LZCANTP��PPaxr NAME�^ <br /> �'c"A "tiB�•f SIONAIVRE // 1 <br /> LE 7 :;a, <br /> �. v <br /> DFUVE <br /> i n e'g �P rpmoTowpy <br /> .. <br />