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ncv. L) +,ujij� <br /> SAN JOAQUIN COUNTY '1BUC HEALT?I SERVICES 8 'ENVIRONMENTr EALTH DIVISION <br /> �.. MASTERFM RECORD INFORMATION <br /> DATE I 0w.IR 10N I 0(J ODICuff <br /> OWNER FILE <br /> COMPLETE THE FOLLOWING BUSINESS OWNER INFORMATION: CNEcxw OwNERCURRENDYCNIuwaNEHD ❑ <br /> &.swiss 0..NN.,f RpNf <br /> Czos I/6//- <br /> 1 Lasf <br /> &suM N.f(4 DIFFEREMh Buvnu Noma) SS SCK SfC/iAX IDf <br /> v <br /> OwrvER HOMR AW" <br /> kh <br /> GN STAD Lr <br /> OWNER MAUNC An m (a DIFFERENT rtom OwnerAddreu) AtIenT :Cx Ccre al (r�IbnaO <br /> Mdhng Admeu CIN // / �� 51We Lp is fr ZO� <br /> L DYR C/R_ 7.J <br /> rvR!W Owrv[RLnr <br /> CORPORATIONS INDIVIDUAL PARTNERSHIP C LOCAL AGENCY COUNTY AGENCY $TATE AGENCY FED AGENCY IS OTHER t <br /> FACILITY FILE <br /> v A G <br /> FACIIIIY D a O I�-"F`, CRO55 REF IDf ACCOUNT ID a <br /> COMPLETE THE FOLLOWING BUSINESS FACILITY INFORMATION: <br /> &a M/FACIV NAM'(TEes"I fE me NAME oN THE HEALTH PERMIT) <br /> al r <br /> FACIurr A.aR oRCN,neSSMV Aoon Sun[f lLNNfss PHONE <br /> E e zcq l6R67 <br /> cm oa COAV-,LSSARi ALIORfRS $i� Lr ��� <br /> gpum Oi SFEvit50R D¢mC1 locAlgN CaoF xM U'2 <br /> HEALTH PERAIR MAIUNG ADDRESS(A DIFFEREM ham Po Oty Atlreu) AnenB .a Caen tcpf 0 <br /> Nlmhnq AOCreu CW SAD W <br /> SIC Caof APN COAiMfM <br /> AccofoyTADog7, for tees and charges OWNER FACILITY/BUSINESS <br /> B LLING AND COMPLIANCE ACKNOWLEDGMENT: 1, the undersigned Applicant, certify that T am the Owaer, Operator, or <br /> Authorized.Igen! of this Business, and 1 acknowledge that all P£RSUT FEES,PENALTIES, ENFORCEMENT CFLARGES and/or HOURLY <br /> CHARGES associated with this operation will be billed to me at the address identified above as the ACCOUNTADDR£SS 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 perforated <br /> in accordance with all applicable SAN JOAQUIN COUNTY Ordinance Codes and/or Standards and STATE and/or FEDERAL Laws <br /> and Regulations. b"71(ACC IINIQ Ta .S/9F , / • �LM SIGNATURE <br /> APPIICAM NAME(Rema PM0 <br /> TITLE lq.o(OCOPIRG,IOlo) '�T <br /> App ed By� D 1 A B u 0mce P sslrq Compi to BY Dale (0`5 I <br />