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REQ/.. 04/09/99 <br /> � $AN .IOAQUIN COUNTY PUBLIC HEALTH SERVICES 8 ENVIRONMEN' iEALTH DIVISION <br /> MASTERFILE RECORf)INFORMATION <br /> GATE OwMR ID Y p� pD(�(03 3 cA:E Y <br /> OWNER FILE <br /> CHfCKIF OWNER CURRfNRY ON FILE WIIN END ❑ <br /> COMPLETE THE FOLLOWING BUSINESS OWNER INFORMATION: <br /> RaxE <br /> BEeuxss OwxEe NAME <br /> us! asl <br /> Sac SEC I TAx ID Y <br /> BwxEss NAME(d DIFFERENTHome) <br /> Ow wHOMEAmREss <br /> 5 AR LP <br /> Oily <br /> Ow ERMAld6ARDREss (VDIFFERENTIrom Owner Add") ABenllon:pCared (apMonaO <br /> Side Op <br /> Mdilnq Atldreu Gary <br /> hR Cf OwNF715niP <br /> CORPORARON If INDIVIDUAL PARRJERSHIP LOCM AGENCYdn COJNrfAGENCV1V1 STATE AGENCY FED AGENCY Ik OTHER <br /> / FACILITY FILE <br /> FACILITY IDM O O Io 1 CROSS REf IDY ACCOUNT I I I <br /> COMPLETE THE FOLLOWING BUSINESS FACILITY INFORMATION: <br /> B .M/FAC.0 NAME(F.w+u N.NAME ox RIE HEALM PERIAD) <br /> .A� w <br /> Sort Y BECINEss PxoxE <br /> FAauEr ADDR1f oo COMM¢sARr ADDxss <br /> .��o Svcs <br /> S'1 Lr <br /> `c`moew'c`or.w¢uR+AnoREss C� <br /> WO OFS`,K E D6MCI lOumN CODE Knl KEVZ <br /> HEALM PERHIR MAILING ADDRESS(M DIFFEREM homF Ilty Add(ess) AH. :a Care OI(Vii-IDO <br /> S AR OP <br /> Mmlln9 AtltlresE City <br /> SIC CODE APN COMMEM <br /> ACDWMADORESS for fees and charges OWNER FACILITYIBUSINESS <br /> 1111JANC. AND CONIPI.IANCE 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 FEES,PENALTIES,ENFORCEMENT CHARGES and/or HOURLY <br /> C1I:tRGES associated with this operation will be billed to me at the address identified above as the ACCOUNTAIIRESS 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 /> PMq <br /> "MCAM NAME(Reaw SIGHANRE <br /> TRIE (Rroc� L �ID) <br /> Apel ed By D7-1 <br /> A X q OIA P vl q Compl ted By Dde <] <br />