Laserfiche WebLink
REV. 0410DIDD <br /> $AN JOAOUIN COUNTZ`� PUBLIC HEALTH SERVICES 8 ENVIRONMEN HEALTH REVISION <br /> MASTERFILE RECORD INFORMATION <br /> t <br /> OWR IDE/ 1 <br /> NE <br /> !/E OWNER FILE CHEC<IF OWNER CURREN11YONPEEWI.EHD O <br /> COMPLETE THE FOLLOWING BUSINESS OWNER INFORMATION: pl O <br /> 9V/NFII OW RNMIE <br /> at <br /> 5E <br /> $PC YC/(A%tD 1 <br /> Z <br /> Bu51EEiSS NAME(YDIffERE noun BUEYEets FEome, \ �� � <br /> C. <br /> OWNER HOME AWHss <br /> ally SSD <br /> Anennav arcaed (OPYonPo <br /> OWNERMIuuNPAOPREss (YDIFFERENTBom OWneEAdtlress) <br /> slate LP <br /> Mating Addeo Cm <br /> 1YRo OWNE1sH11: <br /> CORPORATION 4 INDIVIDUAL PAR)NERSHIP LOCAL AGENCY COUNTY AGENCY STATE AGENCY FED AGENCY r OTHER a <br /> FACILITY FILE <br /> FACINTY IDM O��w CROSS REF IDE ACCOUNT ID M <br /> COMPLETE THE FOLLOWING BUSINESS FACILITY INFORMATION: <br /> BURNEss/FAcw,NAME((r6 Waa a THE NAME ON THE HEALTH PEREAR) <br /> 0' <br /> - BIATfY [Z)PjF�MYA�SSMC�M� SS <br /> 6 �� <br /> C C` LCKJ�x� nµ <br /> cm oR caMAessARY ADDREss <br /> C <br /> poARo of SuourmsOR DdI LocnRON COOS KEPI KEYZ <br /> Allwhan:W Cae Of(WfiOnan <br /> HEALM PERMR MAiUNG ADDRESS(B DRFERENFBom Poc ly 4d '") <br /> STAN <br /> LP <br /> MaIIRp Address Clry <br /> SICL.� APN CCMMEM <br /> ACCTor lees and Charges OWNER FACILITY/BUSINESS <br /> BILLING. AND COMMA ANCI: ACKNOWLEDGMENT; I, the undersigned Applicant, certify that I aro the Owner, Operator, Or <br /> Authorized Agent of this Business,and I acknowledge that all PERMIT FEES,PENALTIES,ENFORCENIENT CI/ARLES and/or HOURLY <br /> CuARGt.'s associated with this operation will be billed to me at the address identified above as the ACCOUNTADORES.S fur this site. 1 <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 /> APPLICANT NAME(Ple PWT) S�IpG�yN�ACIVCR�E����SFI <br /> I TILE IPEEOtOCDVIVEa.IGFO) ,�(( <br /> Appoved BY Dae AccounBng OMce PEocessing Completed BY <br /> / -a - II -DDo`� <br />