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07/11/2005 10:29 209625 CF PAGE 02/02 <br /> "JIM, <br /> 1' '" - ••r TY7 Ilgpn <br /> CITY OF MA �+ <br /> 1 ✓y� �� W� I{tl r.lbI n'p huw- <br /> 9�,m,El .2� ,4„M1.r. lul o kl' <br /> 8r` GREEN FORM <br /> DATE �I I '6y MASTER FILE PIr^ORD INFOOMATI^” ttli <br /> dltu , l:iii u, 1�N12lnlilll51 iu1• —1 UNIT IV <br /> SMDEt nAEAO cop EHOu aHLY di <br /> OWNER FILE <br /> COMOLETFTHE FOLCOhWlN _GPROP ERTYOWNERINFOO4ATION.• C+'the+t+rOWNERCaaaENr;roNatFanrMEND <br /> PROPEAYY PHONE <br /> OWNER NAME <br /> nyl MI 4n <br /> BUSINESS NAMEn $OC SEI:)Ta%ID>H <br /> Cir O 1` f 0- iL _ <br /> Owner Nome Address = Ln,„ .. 1 r r �.-f-. DRIVER'S LICENSEN <br /> IAJ 4 I <br /> city M+e-L� ZIP <br /> I O+Iner Mailing Addreet - �_� GA� <br /> Mailing Address City State LZIP <br /> �Co <br /> APORATION❑ INONIOUAL PARTNERSHIP❑ FEU AGENCY r OTHER❑ <br /> FhCIL.ITV DILE <br /> 1I1 " W ;1 I' 91"' d efAtl I i, itlt..I "t r„1" "C i illi n• I 'I II 17F1{ •.Lp LI,1� t�Fli III � ylla,lf: <br /> OAfPL,ETETHEFOLLOW/NG B.USIWESSI FACILITY 1 SITE TV FILE <br /> IS thl:A MEW Bgslness LOCATION net io erio o't regulated by the ENVIRONMENTAI,NEA6TN r)IVI"a 4 YES ❑ No ❑ <br /> IS tHis m E)USYING BMsinese LOCATION but a NEw TYPE of regulatad RusinasS? 1 4 Yes ❑ No ❑ <br /> BuSINESSIFAGU.IrYISITE NAME G 4 Plat-4 -col_ <br /> I <br /> SITE AOORESS �--� 5 y l C .N •� SUITE f1 BVSINESS PHONE CITY R-Co, V w" •` STATE C.ZIP <br /> i Illi 91ru '�I By 11 7 <br /> 51` "'" bill 7 III ill'I Ip11Nn I (I ( I C r;1r 'fS"�-H�'r lid" iw yl li. <br /> f � �ilk ? !�':r �IJ�; I ,: !�� e I� fui� � � ��TII,�I�: . V,I: <br /> Mailing Address!rD1FFERENrfii2rH F?e//Jfy Aertrress Attention; or cars Of(optional) <br /> `Mailing Address City STATE ZIP <br /> file <br /> d>,'6> ,m,.tihtllGllI1�l, Plllf$IIIIIIK'lll�� I1 � 1��r4'r!IIIIIh#cll <br /> THIRD PARTY BILLING INFO: Complete if EIIIII is different from Property Owner orFacitity Operator idani fredebove. <br /> EIMNIRa NAME Attention: or Care Of (o PJJ7 <br /> Mailing Addreae NONE - <br /> Cor ar <br /> A_ocauNr OORf6S for fees and charges OWNER FACIUTYBUSINESS <br /> Twlli547 Y JILING <br /> QIu.INr:+No COmrLIIANr):.dGKNO'NI�OGMQJS: 1.Out 41vdenigned APPIICaai,certify that f Am the ishm r,0p Cruor,or AAradritedAsemt of this]baiaefd.and I-CIAnwledRe That A, <br /> PaRAArFM,AXW..rrs•,BNFPAtrVZrr C%AMBS and/or ROd+GrCFA1RGES assDaialed With MIS operation Will be Titled tome at the+Iddrea identified above a9 the dgagxl'AmME' <br /> rarihia Jlte. I alto dertitY that all lntoran.tlon urevidM nn fair annlidrem It rr...e.d m.,.ee•..A N+r.11.w.br«1..IWn:_..:n Iu...A.ww.A 1....r.A..uw r:,N.a.Mr...e..e.. <br /> .ronOVov CounTY Ordinnna Cedn Aauror Sanaertip and 4rnt6 aatl/er b'>:Dr,ML IA"nod RcgulollOax A.t Me undersigocd owner,openitur,or agent or ilia property located at de <br /> abort fl tilitylSIR addren, I hereby aRlhoriac the relaI of may and all Molts and Nevin merental aesremleat information In SAN.TOAOVIN COUNTY ENVIRONMCNTAI <br /> IIEAI.T(i DIVISION u-loon at it is arallable.nd at thtaame that it IS Provided m mtar my repaveab*1 <br /> PLEASE PRINT <br /> APPLICANT NAME WARREN SHANNON SIGNATURE <br /> TITLE trRIVCp'C I InaMS. • _ <br /> WAS R JER SYST) Pis SUPFR.LNTEiVAENT -adarnr�wneeiilgp`g5 <br /> IM"�.i IVy I,. 71 i,.rc I r t ISI"N• .,.q.,a.,i�,.e-.-.n r.. ar'`Ut"w 1 r�'4�. f � ', Ir n <br /> :�lt�i a��W' i f II�I�ivi�l d 1 � ��I�IICI LI '� tfallh .�I 't �I6�tkl��]� I •7r^ "_ 'Tylto ��I��IL1 "°.4�.'�l '' ,ialil <br />