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12/30/02 11:27 FAX 1a002 <br /> 12/30/2002 10:51 209463 FSFTH FLOOR PAGE 02 <br /> gS� BNro ME <br /> DAVE WASTER FILE RECORD INFORMATION roRlt 1®N ooad i Fnaeo aantren <br /> ° UNIT IV <br /> OWNER FILE <br /> ...E_04.._..1__...._ _—____.I............. M eWIP OWNER etMtftBMTLrexga IN/TMEHO <br /> COMPLtTE rHEFOI.LpWfNG BUSINESS OWNER /HFORMAT/Ox: G <br /> fAFSIPlESS PHONE <br /> OvmpR NAME I ' <br /> '..8UMNESSNAME(if a606ntlflif lifil Water P'OMO) ^E{I$EC/TiNfIO* <br /> I <br /> i 01ANIMHONl:AgOR[SS I i <br /> . Oatvelesurata�s , <br /> ` chY i STATE 1 by <br /> ' I I <br /> OwNFAMAIUNCAUCaEsa (llpIFFERFMdtim tlwrre.AGd'sasJ ! Af�rdiett.a^Gre of lMp�y, yn <br /> Mai4wg Addr0.t3 City yeK� i <br /> p <br /> CORPONATION❑ INg1V1pMAL❑ paizme ampu. Ll)CALA3'icylM COUNTlA=NCY❑ STXMACEN4 [Z FwAtr'F.NI III OTf¢'n❑ <br /> FACILITY FILE <br /> COMPLI rETH&FoLLOWINC BUSINESS/FACILITY I SITE INFoRMArIQM: <br /> IS Ursa NEYl Bdeineas LooAirON nohprevhansty regulated py the FlaNligwMl3.RALHPALTN()IY®ItwaT Ys 0 NO 0 <br /> Is this an FASTINA ewheIes LOCATION Ruta NEW Tfpr of MvullI 6u lino 7 Yes 0 I No ❑ <br /> Busli, IFACIUTY/SITII NAME <br /> $ITE ADgRT?;S �• , 9UrrEdt IMIaIgSS PNONEI <br /> I I <br /> CITY � r I <br /> g <br /> Mailing Address ifOIFFERENrfiom FsrArtyAeldres: Atlandam rM ire Of Imo) r <br /> Mailing Addlsaa City STaYE 1 ZJP <br /> THIRD PARTY BILLING. .. . . 4444. .... <br /> INFORMAYIONp Cerrrp/efe if Billing Party isd%tJrereftt firm Business Owner ldenitif/ed above. <br /> 5LL91x935 NAME t� Atban Wn a Care Of l /' <br /> �j�� Q r <br /> Mailing Address <br /> _ I <br /> Cm -` SYA 2tp <br /> ;Ito) <br /> Ara2gyrAngAM for fees and charges OVI FACILITYIEUSINEss THII PART,13n-l-vmoY�7'`.. <br /> P&k Ne CenmL rat AarnomxneMsxr 4 rhe andendemed APPhaatt.ee>11Sy Mao I mI tin:6,1()pe er a.ired,gyeiv erthl,ll—'Mend IIeFfinxledge alae aS <br /> eFAWT PZ=PtIgtTiFs,ANF411=4111r CZAACM ad/or ROf1BL1'C{U =waaaiated with this apene�a Trill be haled:to 8caddresaldemi&ediyova an dre <br /> SCSS AII <br /> far tilde Aim ;31 CMfY that all iofonmadaa pe,a-Wed aA thic applintrov 6 o-°a and wrrvak and dud aS ag.lared aadvides Will he perfarmea In acavrdastt vdth all <br /> aPplTnNe SA7i JgAGCaa COUI 01 Cadet WI Standards and STATS aad/ar JI Lim and Nguladoea. Aa the und"co od owr.uar.eeerateor agen't of the pniI <br /> IarJlyd the above faxilityleiw addecss, ; hSeely mrhaNze the M. of env aad all retWanmm <br /> h and eovheal atetisrTI 11110177111 to SAN JOAQUIN COUNTY <br /> ¢ Nhzmvl'AI.I'�AI,TA DMSION as noon as M is avyiWafe�d aetge lama rime 1[k pmtided to me ormy repa'esco - <br /> // _ ����7777 Pta:.AsE PI <br /> APPLICANT NAME ��y�/tr.� (7��� ._` SIGNATURE <br /> TITLE PI—V�g,`� Y 'll/L`�1 s'1 CRIVEIi'S LtOENSE 9` <br /> - fAHomrn�.-v ePOt^OcnAFornacnl <br />