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htv. u4/uy/yy <br /> SAN OAQUIN COON' PUBLIC HEALTH SERVICES 8 ENVIRONME HEALTH DIVISIOt# <br /> •- MASTER���tttFILE RECORD INFORMATION <br /> DATE /—J,)- v J� OWNER IDY D / 4 <br /> 4 7J JY CMEI y <br /> OWNER FILE <br /> COMPLETE THE FOLLOWING BUSINESS OWNER INFORMATION: _Q)/y� C„E/CKK,F OWNERCURRENnrO„ <br /> BIE1Nf55 rufw/„�„fHD ❑ <br /> GwNER NAME 1 V / `// E 1 I V <br /> s! M1asl <br /> "NEssN (MDIFfERENThwn ma) _�S SOC SEC/TAZIDB <br /> aWNfR HCMf ADD L <br /> e' <br /> City s7 n <br /> O.ERM.uune AvmM (NDIFFEREMRa"n Ow Addle”) ABentlan:or Care N (op6atap <br /> Maung Address City Slae 31p <br /> hFE aF GWNfRSMIP <br /> CORPORATIONS A INDIVIDUA1.4111171 I PARTNERSHIP LOCALAGENCYCI I COIJIMAGENCY47 I STATEAGENCYmn FED AGENCY{ OTHERa <br /> { /Mq/(5'z FACILITY FILE <br /> FACILITY ID# r CJCROSS REF IDY ACCOUNT ID# <br /> COMPLETE THE FOLLOWING BUSINESS FACILITY INFORMATION: <br /> B NE /AOMNAME(T„uvnummff NAMEaN ENEAIM PfRMRC) <br /> G V S <br /> FACn11YADOKMMCdAMWS 'A(MRE a BWNFSS PIp„f <br /> ri V00 1 ` <br /> CV al r y ss Ss4 110,L� <br /> A-1 [/�{✓1 <br /> BOAAD CE$UrERVL50R Damon 03 LCCA CODE KVI KEY{ <br /> REALMPERNIRMAILINGADDRESS(NDIFFEREWb Facety Adaess) AMenXon:w Cae OI(opM o <br /> Mailing Addrom CIN STAR Lv <br /> sic Cam APN Ca`.rW <br /> ACCOurrrAeDRgs (fees and charge$ OWNER FACILITY/BUSINESS <br /> BILLING AND COMPLIANCE ACKNOWLEDGMENT: I, the undersigned Applicant, certify that I am the Owner, Operator, Or <br /> Authorized Agent of this Business, and I acknowledge that-all PERMIT FEE'S, PENALTIES,ENFORCEMENT CHARGES and/or 110URLY <br /> CHARGES associated with this operation will be billed to me at the address identified above as the ACCOUNTADDRESS for this site. I <br /> also certiry that all information provided on this application is true and correct;and that all regulated activities will be performed <br /> in accordance with all applicable SAN JO"AQUIN COUNTY Ordinance Codes and/or Standards and STATE and/or FEDERAL Laws <br /> and Regulations. <br /> APPLICANT NAME(Noose PMI) SSIIpGNN�ATUR�E(�(�5E <br /> nTLE (Rq(aCDT'➢FOLIDID) <br /> Approved 3, Date Aecouniing Omce Prones rg Completed By Dale <br />