Laserfiche WebLink
'NEVR'h4/09/99 <br /> SAN JOAQUIN COUNTY 8 UBLIC HEALTH SERVICES 8 ENVIRONMENTAL EALTH DIVISION <br /> MASTERFILE RECORD INFORMATION <br /> DAT OWNER IDN CASEN <br /> OWNER FILE <br /> COMPLETE THE FOLLOWING BUSINESS OWNER INFORMATION: CHECKIF OWNER CURRENTLYONRU WMEHD ❑ <br /> BIEINESSOWNERNPMF <br /> RHONE <br /> ri/sr 'St (7/( "/✓/�1C_/ 1L V') IVB <br /> 9USINF35NAM (HDIfFEREM horn Nwne) SOCSEC/TA%lDN <br /> OWNERHCMEADPRFSS <br /> city 1^J tom//!Vl <br /> STALE /'� Dqf <br /> OWNERNWUN A)q (IIDIFFERENI` w Aa.) Attention:wrote N (opNarao <br /> Mailing Address City Slate lip <br /> T'FE OF OWNERSHIP. <br /> CORPORATION d INDIVIDUAL 07 1 PARTNERSHIP IC I LOCAL AGENCY 4C COUNTY AGENCY 47 STATE AGENCY dF FED AGENCY t nn-ERs <br /> FACILITY FILE <br /> FACILITY ID# CROSS REF IDN ACCOUNT ID# <br /> COMPLETE THE FOLLOWING BUSINESS FACILITY INFORMATION: <br /> BUSIM5/FACIMNAM (THLS W1u KTHENPME0>1HEM TH RMR) <br /> F/CJIl1Y CCMMISSAW AD0RE6 S ^rV�)A/`/ SULLEN llt&Niiss 1 w <br /> CfIY ON COMM ///gppRESS STAT �. OP <br /> �r7 16 <br /> EOMD OE SIIPEINI5oR D6iIdc.T LaCAnPNCODE QxI KEY2 <br /> HEALTH PERMR MAILING ADDRESS(iIDIFFERENT(an FacYMy Address) Allenlion:w Cwe Of(op/brao <br /> Mating Address Gfy <br /> SlNIE LY <br /> SIC CODE APN COMrNENt <br /> CCOVNTADORESS for fees and charges OWNER FACILITY/BUSINESS <br /> BILLING AND CONIPLGINCE 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, PE;VAL77ES, E;YFORCC:Y7E.VT CHARGES and/or HOURLY <br /> CHARGES associated with this operation will be billed to me at the address identified above as the ACCOU.VTADDRESS 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 /> APPUCANT NAME(Rease PMo SIGNATURE <br /> TRIE <br /> IaNO(OCDW REOUIREp) <br /> APProvep fly Dae Accaanling OtBce Procesung CwnpleleO BY Date / y <br />