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REV. 04/09/99 <br /> t SAN'JOAQUIN COUNTY1 PUBLIC HEALTH SERVICES 3 ENVIRONMEN' HEALTH DIVISION <br /> MASTERFILE(((RECORD INFORMATION <br /> DATE / OWNER IDY /1D�G � CASEY <br /> / C/ OWNER FILE <br /> CMECXIF OWNER CURRENIIY ON FILE WITH EHD a <br /> COMPLETE THE FOLLOWING BUSINESS OWNER INFORMATION: <br /> BIaiNEss OWNER NAME <br /> vs; ast <br /> SOC SEC/TAA ID Y <br /> BLAINESS NAME(Y DIFFERENT hom Business Noma) <br /> OWNER HOME ADDRESS � /_ ( �� J�/ +_'/ p ✓ . <br /> Gly STATE�� � La <br /> Altenhon:or Care of (op Norio <br /> OWNER MAIuNG ADOREss (Y DIFFERENT nom Lav e(Address) <br /> Slate Zip <br /> Maling Address City <br /> TYPE oP OWNfRSriIP <br /> PARTNERSHIP LOCAL AGENCY COUNTY AGENCY STATE AGENCY FED AGENCY d OTHER <br /> CORPORATION INDIVIDUAL <br /> FACILITY FILE <br /> FAC:'I Iry If)ft GROSS REF IDY ACCOUNT ID)t <br /> COMPLETE THE FOLLOWING BUSINESS FACILITY INFORMATION: <br /> Bls+r+Ess/FAaurr NAME(Ttiu vnu BE THE NAnIE oN THE HEALTH PERtAR) <br /> SUM Y BusNEss PHONE <br /> FACIIfTY AOORESS OR CC+.IMlLSARY ADDRESS <br /> STATE La <br /> Cn OR CO&%IiSSARY ADDRESS /1,L <br /> 7 <br /> KEr2 <br /> BOARD Of SUPER'JISOR DISTRICT LOCATION CbOE KEYI <br /> Attenhon:or Care Of(000000 <br /> HEALTH PERMIT MAILING ADDRESS(Y DIFFERENT hom Focd ry Address) <br /> Mailing Address Clry STATE � <br /> sic CODE APN COAIMEM <br /> I <br /> AccouNrADDRgss for fees and Charges OWNER FACILITY/BUSINESS <br /> BILLING AND CONIPI.AANCE ACKNOWLEDGNIENT: I, the undersigned Applicant, certify that I am the Owner, Operator, or <br /> Authorized Agent of this Business, and I acknowledge that,all PEKWIT FEES,PENALTIES, ENFORCEMENT CHARGES and/or HOURLY <br /> CHARGES associated Nvitil this operation will be billed to life at the address identified above as the AC'COUNTAmmESs 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 JO.AQUIN CUUN'FY Ordinance Codes and/or Standards and STATE andJor FEDERAL Laws <br /> and Regulations. <br /> APPLICANT NAME(Please Print) SIGNATURE <br /> TITLE (PHOTOCDPYl Zto <br /> Approved By Dote Accounting Olflce Processing Completed By / Date <br /> / <br />