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REV. 02/16/00 <br />SAN JOAQUIN COUNTY a PUBLIC HEALTH SERVICES ' ENVIRONMENTAL HEALTH DIVISION <br />MASTERFILE RECORD INFORMATION <br />DATE OWNERID# b�o� ((I a1 CASE# <br />OWNER FILE CHECKIF OWNER CURRENTLY ON FILE WITH EHD ❑ <br />COMPLETE THE FOLLOMNG BUSINESS OWNER INFORMATION: <br />BUSINESS <br />OWNER NAME <br />FACILITY ADDRESS OR COMMISSARY ADDRESS <br />SUITE <br />BUSINESS PHONE <br />CITY OR COMMISSARY ADORES$ <br />,V`-IYVT <br />PHONE <br />zipLP 6162-1)(o <br />V/�! <br />FFsI <br />MI <br />K�EYZ <br />Last <br />Attention: or Care Of (optional) <br />BUSINESS NAME (If DIFFERENT from Business Name) <br />STATE <br />SOC SEC I TAX ID # <br />OWNER HOME ADDRESS <br />APN <br />City <br />COMMENT <br />STATE <br />LP <br />OWNER MAIUNG ADDRESS (If DIFFERENT from OwnerAddress) <br />Attention: or Care of (optional) <br />Mailing Address City <br />State <br />Zip <br />TYPE OF OWNERSHIP: <br />CO PORATONINDIVIDUAL PARTNERSHIP LOCALAGENCY <br />COUNTY AGENCY STATE AGENCY FED AGENCY OTHER <br />�1 FACILITY FILE <br />FACILITY ID # t) C r (o D CROSS REF ID# Account ID # A kooa q <br />e,n MUI =T=Tuc Fnt I nlAnAlr_ RI ISBJFSS FAC(( ITV INFORMATION: <br />BUSINFAS1 IFAC11,11TY NAME HIS WILL BE THE� I VAMEON �O E HEALTH U S MIT) <br />LJ <br />FACILITY ADDRESS OR COMMISSARY ADDRESS <br />SUITE <br />BUSINESS PHONE <br />CITY OR COMMISSARY ADORES$ <br />,V`-IYVT <br />STATE <br />zipLP 6162-1)(o <br />V/�! <br />BOARD OF SUPERVISOR <br />LOCATION KEY11 <br />K�EYZ <br />HEALTH PERMIT MAILING ADDRESS (if DIFFERENT from Facility Address) <br />Attention: or Care Of (optional) <br />Mailing Address City <br />STATE <br />LP <br />SIC <br />APN <br />COMMENT <br />AccouNTADOREss for fees and charges OWNER FACILITY/BUSINESS <br />BILLING AND COMPLIANCE ACKNOWLEDGMENT: I, (lie undersigned Applicant, certify that I am the Owner, Operator, or <br />Authorized Agent of this Business, and I acknowledge that all PERMIT Pecs, PEIVALTIGS, L'NFORCEAfENT CHARGE'S and/or 11OURLY <br />CIIARG&Y associated with this operation will be billed to me at file address identified above as the ACCOUNTADDRESS 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 STATE and/or FEDERAL Laws <br />and Regulations. <br />