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REV. 04/09/99 -- <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES 8 ENVIRONMEN EALTH DIVISION <br /> MASTERFILE RECORD INFORMATION <br /> DATE / .,�D_ DWNERIDI DOola7 "" <br /> 5 ` <br /> OWNER FILE CNECKR OWNER NRRENnY ONnEE wire EHO <br /> COMPLETE THE FOLLOWING BUSINESS OWNER INFORMATION: <br /> n PHONE <br /> ErdNEiS OWNFR NAMf �M I <br /> fiV I D / L ' asr -Joel <br /> o <br /> vsr <br /> soc SEC/TAK 10• <br /> SrenassN (X DIFFERENT Rorn me) <br /> Gwa+fv HaM[Am�ss I. // . <br /> STMT A LE q5�1� <br /> CIN <br /> Anenllorl:Or Cole Of topRonaO <br /> OWNER Muuw AWRSf (MDIFPEREMRan Owner Atldrea) <br /> Stole ZIP <br /> Mdbral AEW."ON <br /> TYRE rK Owwlr MP <br /> INDIVIDUAL PARMERSHIP LOCAL AGENCY COUNTY AGENCY $TATE AGENCY FED AGENCYIli OTHER <br /> lk <br /> CORPORATION <br /> FACILITY FILE <br /> FACILITY ID It <br /> �� p 93y � I CROSS REF ID ACCOUNT D M D" <br /> COMPLETE THE FOLLOWING BUSINESS FACILITY INFORMATION: <br /> green fRaMN.wE(TNevnue r,%Nu%ON EHEAUH PERMIT ,rr, ( /�� <br /> faun Amassa•CW'MrStMY ACORfSt l A/1 <br /> = R DP95a� <br /> cm aR vniswY uwv[ss <br /> A/ KEvI KFY2 <br /> aouroawnRvmROutma locwnoNCooE <br /> Anennm:or care Of topllona9 <br /> HEALM PERMIT MAKING ADDRESS(R DIFFERENT Rao FocwN Add'Ou) <br /> VAR 7✓ <br /> Mailing Addres,CIN <br /> Gwanua <br /> SIC CW[ APN <br /> AccauNrARoaEss <br /> for lees and charges OWNER FACILITY/BUSINESS <br /> Fsc=Azo Em <br /> ItI1.1.ING AND CODIPIAANCE ACKNOWLEDGMENT: I, the undersigned Applicant, certify that I am the Owner, Operator, or <br /> Authorized Agent of this Business, and 1 acknowledge lbat,all.PEBbIIT FEES, PENALTIES, ENFORCEMENT CHARGES and/or HOURLY <br /> CII.IRGI:s associated with this operation will be billed to tire at the address identified above as the ACCOUNT Ss for this site. I <br /> also certify that all information provided un this application is true and correct;and that all regulated activities will he performed <br /> in accordance with all applicable SAN JOAQUIN COUN'PY Ordinance Codes and/or Standards and SPATE and/or FEDERAL Laws <br /> and Regulations. <br /> SIGNATURE <br /> APPLICANT NAME(Pleaw PMI) <br /> TME IMDfOLD%'RWRIo) <br /> s+Ing CaIeleE EY Dal" 2 <br /> Y <br /> / <br /> Approved SData /.-� n�� Accoannng 011lce Rocamp <br />