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�.EV. OIO9I99 g PUBLIC FIEALiH SERVICES 8 ENVIROHM L HEALTH DIVISION <br /> SAN JOApU1N COUI <br /> MASTERFILE RECO^�T(R��DANFORNIAIIUN <br /> GWNFR IDY �lJDO II IO3V CAFFI <br /> GATE <br /> OVVHER FILE C.ECYIF OWNER CU"1NRY0NFIIEwIrHEHD ❑ <br /> COMPLETE THE FOLLOWING BUSINESS OWNER INFORMATION: <br /> yaweY OW kNAME <br /> asf <br /> nsl <br /> Mi <br /> Soc s!c/TAa ID Y <br /> e�mnus NAMF(YgIfiEAEMhom&+�+refE NamuJ <br /> (IMM[R MCM!ACORlLf <br /> STAR Lr <br /> aN <br /> DwNFR M�uw+a Alwxss (YDIffFREMhom OwnefAddress) ARenMon:wCareof (apllonaD <br /> Sloe IIP <br /> Malog Adaeu City <br /> M1K w OWNFRF <br /> CORPORARON a INDIVIOUAL - PARTNERSHIP LOCAL AGENCY COUNTY AGENCY $TATE AGENCY FED AGENCY lk OTHER <br /> I' FACILITY FILE <br /> y/,Q� <br /> FACILITY IDR d�I� � IT CROSS REFIDa ACCOUNT IDM <br /> COMPLETE THE FOLLOWING BUSINESS FACILITY INFORMATION: <br /> eu%/FACI rvN. '(Treses u ME NAME on ME REALM PEW.iq) <br /> FAyafsn_ARoxss oRcwMscsARr Aaoxss Surto eTmNEssPMMf <br /> Cm w cere.a y Ns, 51AR Lr <br /> poAwaSWERRSav DemCt lOunaN DORf K"I KEY2 <br /> REALM PERMR MAIUPIG ADDRESS(Y DIFF£AEMharn faculty Addfem) Aaen Man:a Care a(WW,,00 <br /> Mating Address Clry STAR LP <br /> SIC CCaf MN CCMMFM <br /> AcCNNTADDREss to,fees end chotges OWNER FACILITY/BUSINESS <br /> BILLING AND CONIPLIANCE ACKNOWLEDGMENT* I, the undersigned Applicant, certify that I am the Owner, Operator, Or <br /> Authorked Agent of this Business, and I acknowledge that all PERMIT FEL'S,PENALTIES,ENFORCEMENT CHARGES and/or HOURLY <br /> C/IARGF.'S associated with this operation will be billed to me at the address identified above as the ACCOUNTADDRFSS for this site. I <br /> also certify that all information provided Un this application is true and correct;and that all regulated activities will be pe'rforme'd <br /> in ac'cord'ance with all applicable SAN JOAQUIN COUN'I'Y Ordinance Codes and/or Standards and STATE and/or FEDERAL Laws <br /> and Regulations. <br /> "MCAM NAME(Rectae PMI) S��IppGIIyyN��AppNyyR��EfE��������c <br /> Mu (PfiafOCDPlREc.41DlD) <br /> Appaaved SY Dale AccaanMng Ofte Ptacessng Ca pleled SY - Dale !)3 <br />