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REV. 04r09/99 <br /> SAN JOAQUIN COUNTY +PUBLIC HEALTH SERVICES 8 ENVIRONMENTA�:>rALTH DIVISION <br /> MASTERFILE RECORD INFORMATION <br /> DATE <br /> OWNER ID 1 dOO C1819:p- CASE 0 <br /> OWNER FILE <br /> CNFCKIF OWNERCuaaENnroNNLEwRHEHD <br /> COMPLETE THE FOLLOWING BUSINESS OWNER INFORMATION: <br /> PHONE <br /> BUSINESS OWNER NAME <br /> rs; Last <br /> BusiNisE NAME(it DIFFERENT from Business Nome) SOC SEC/TAX 10 r <br /> OWNER HOME ADDRESS <br /> STATE L► <br /> Gty <br /> OWNER MAILING ADDRESS (II OWFERENT from Owner Address) Attention:or Care of (opBOrlan <br /> Stale Zip <br /> Mailing Address GN <br /> TYPE Of OWNEiRsnlr <br /> CORPORATION i INDIVIDUAL PARTNERSHIP LOCAL AGENCY COUNTY AGENCY STATE AGENCY FED AGENCY tE OTHER a <br /> FACILITY FILE <br /> FACILITY ID If ?OIA406jl CROSS REF ID II ACCOUNT ID►R <br /> COMPLETE THE FOLLOWING BUSINESS FACILITY INFORMATION: <br /> BUSINESS/FACKirr NAME(TNLS Wlu M THE NAME ON THE HEALTH PERMIT) <br /> D l hu/ <br /> SUITE! BUSINESS PHONE <br /> FACILITY ADORESS OR COMMISSARY ADDRESS <br /> STAT <br /> CITY OR COMMISSARY ADORESS E Zip <br /> BOARD OF SuPERvuoR DISTRICT LOCATION Cooe KEY I K-2 <br /> Attention:of Care Of(opMonoO <br /> HEALTH PERMIT MAILING ADDRESS(b DIFFERENT hom Foci4ry Address) <br /> STATE L► <br /> Maung Address City <br /> SIC CODE APN COMMENT <br /> ACCOUMADgR!s for fees and charges OWNER FACILITY/BUSINESS <br /> 1111.1.ING AND CONIPLIANCE ACKN0%VLEDGM1IENT: I, the undersigned Applicant, certify that I am the Owner, Operator, or <br /> Authorized Agent of this Business,and I acknowledge that all PERAUT FEES, PENALTIES, ENFORCENIENT CIIARGES and/or HOURLY <br /> Cll.•LRGES associated with this operation will be billed to me at the address identified above as the ACCOUNTAyyRESS for this site. I <br /> also certify 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 JOAQUIN COUNTY Ordinance Codes and/or Standards and S'L'ATE and/or FL•:DERAL Laws <br /> and Regulations. <br /> SIGNATURE <br /> APPLICANT NAME(Pleose Print) <br /> TITLE D F DP(REOl1RID) <br /> Approved By Dafe <br /> Date Accounting Otifce Processing Completed By <br />