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A-25-1999 11 :09AM FROM P- 2 <br /> All <br /> AL1��Dtvt$rotU <br /> GREEN FORM <br /> DATE MASTER FILE RECORD INFORMATION "MFR" <br /> 'eHaDEO APEAi FOR END U]E ONLY UNIT IV <br /> OWNER FILE El <br /> :OMPLETETHEFOLLOW/NG PROPERTY OWNER MfFORMAT(ON: CNECKIF OWNER CURRENrcroNFueanrHEHD <br /> PROPERTY f/n I I PNON <br /> OWNER NAME OHM, � i (TYou5c- E 2 / <br /> ZC2q <br /> cvv/ A <br /> BUSINESS NAME I q, _ .{ y SOC SEC I TAX ID a <br /> �5�c �-NI (t{/G v WLttiLI //�I t <br /> Owner Home Address DRIVER'S LICENSE d <br /> city S t12� STA ECA ZIP s Zvz-- <br /> Owner MOUing Addreaa G <br /> Mailing Address City J State Zip <br /> CORPORATION❑ INOIVIOVAL❑ PARTNERSHIP❑ FED AGENCY❑ OTHFR <br /> FACILITY FILE y <br /> :OMPLETETHEFOLLOW/NG BUSINESS I FACILITY I SITE INFORMATION: <br /> Is this a New Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DIVISION? YES ® NO ❑ <br /> Is this an ExIsT No Business LOCATION but a New TtPE of regulated Business? YES ❑ No <br /> BUSINESS/FACILITY/SITE NAME / I� <br /> _J owe r�c� l <br /> SITE ADDRESS I I SUITEY BUSINESS PHONE <br /> lttmQA (ate '5milk4kh ✓A� 64HHeAt ��A,� yam54, E�t✓U uNw� H(w1, �]Y• �Z,; Wovk.f'NAMtio� <br /> CITY /n / STATE ZIP /,'��D^ <br /> ._.. (�/`'!(rN• �I T-. .a w-.,41 ee r NY"�'.J a ,S r iw7�i.TWOU,Nn 4 Ui, x L r <br /> BOARDOFSUPCRYISOR_ ,. Ii.�a1T10N,...�;_ ..�..L"r...-:.E.K� +�1:° ...:.! .._':i,..11R�w..-._' h,n ...^17'•LL.�.n: r.. ru•N �... � ..5::.,� <br /> Mailing Address ifDIFFERENrfrom Facility Address Attention: or Care Of(optional) <br /> 5122• 0WKW 0&,2(,Ve5� <br /> Mailing Address City STATE ZIP <br /> rHIRO PARTY BILLING INFOI Comp/eteif Billing Party is different from Property Owner or Facility Operator identified above. <br /> 5"l-Ess NAME Attention:orCare Of (optionaQ <br /> Mailing Address PNONE <br /> CITY STATE ZIP <br /> AccomvrAooREss for fees and charges OWNER FACII.rrYlBusmrss THIRD PARTY BILLING <br /> 'aU•ING AVD CUMPL"NCE ACKNOWLEDGMENT: L the andenigncd Applicant,certify that I am the ownev,Operator"or Audhorierdelgrnd of Nu Business"and 1 acknowledge that all <br /> 'PAH?FrM.PEN u.rret,t:.VPORC&WZNr CN rgv andlor HOURI,r CN4A4'FS associated with this operation will be tilled Is me at the addrate identified above m the ALWUNfADDREit' <br /> Ir this sib 1 shin certify that all information provided on this application is true and correct;and that All Mutated activities will be Performed in accordance with Al applicable SAN <br /> OAQVIN COt, Ordiannco Cuda and/or Standards and STATE and/or FXDCRAL law%and Regulmion %a tiM undersigood owner.Opesator.or agent of the property looted At the <br /> bove facility/site addrm4, I hereby audsor'rs the rek"t of any and all rade, and casvonmrutal Aafeevneot Information to SAN dO,%QUIN COUKIY &NVIRONMENTAI. <br /> U:AL'rH DIVISION As sdoa as it is availablc and at the same dme it N provided to me or my representative. <br /> PLE����� ASE PRINT � �i'6/�' <br /> APPLICANT NAME e <br /> �� SIGNATURE <br /> AFPed.Bwi+eRw;wv. r+ip+ts ::�?tr+x�'a.lf.v-.tomI 6 *A�r`eweniocu5vnrtin OHl`o'Q .,G.onYaI.s s/VDwR"C+IoRVoTrEmmvRpr-O'SPLICENSE <br /> IRdCF ENSEf'r D1�N <br /> TITLE p/Iocl d :� Ir <br /> 'r „w 1k. �a.``* I ,. <br /> ..,.. <br />