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REV' 04/09/99 <br /> SAN JOAQUIN COON PUBLIC HEALTH SERVICES 8 c —� <br /> HEALTH DIVISION <br /> MASTERFILE RECORD INFORMATION <br /> DATE OWNER ID Y <br /> &1�5)/D S20A I GASP Y <br /> OWNER FILE <br /> COMPLETE THEFOLLOWING BUSINESS OWNER INFORMATION: CNECYIFOWNERCURRf„nro„NEEwIrNEHD ❑ <br /> BVSNFSS OµNf4 NM1f <br /> Mec u/ ✓ y P� <br /> aF, 73 <br /> Bu+nfss NAME(ADIffEREM Y,orn Buvr,evE Noma) <br /> SOC SEC/Tm ID <br /> Ow RHOMfA wm 7 c / 2Y <br /> cKcA^.�-a GJ,g 7 <br /> Cit <br /> S UCIr— u J BrAf I'A np 13 S201j <br /> GWNfR hIwuNO Anonss (Y DIFFfAEM Awn Owner AtlCreAf) <br /> AtienMPn:wCwed (opflonop <br /> M1lcting ACCIau Gly Gr <br /> Stale LIP <br /> hEF Ci OWNERSHIP' <br /> CORPORAPON G INDIVIDUAL PARTNERSHIP <br /> LOCAL AGENCY liq ICOUNTY AGENCY $TATE AGENCY <br /> ,{ FED AGENCY i OTHER it <br /> FACILITY FILE <br /> FACILITY tnu IF11 _rL <br /> _ <br /> ACCOUNT ID N <br /> COMPLETE THEFOLLOWING BUSINESS FACILITY INFORMATION: <br /> B,slrvfss/FACIury Nun[D„u <br /> -11 mf N.Vnf ON 1E MEALM FERMR) <br /> FAC un AOmM OR CO'Ma "Y AMP <br /> 6 p Y�W S Y BullfssP ONE <br /> CRY Ccl �YA➢O4f� <br /> l/jJ[ILiI Sart zip _ <br /> BOUO aE SuxrrtsoR DulmcE loCAnoN Caof <br /> KEY KE2 <br /> HEALM PERMR NiAIUNG ADDRESS(HDIFFEREM hom Fa d'IY Add,ay) <br /> Atienllon:w Cwa p(opM1awp <br /> Maung Acd,ay City <br /> SiAfF jIp <br /> SIO CME <br /> APN <br /> CQ`nMEM <br /> AccovyTAoDREss lar fees and charges <br /> O NER FACILITY/BUSINESS <br /> IIII.LING AND COMPLIANCE ACKNOWLEDGMENT: 1, the unders >ned licant, certify that I am the Owner, Operator, or <br /> Authorized Agent of this Business,and 1 acknowledge that all PERMIT EES, PENALTIES, ENFORCEMENT CIIARGES and/or 1/0URLY <br /> CHARGES associated with this operation will be billed to me at the address identified above as the AC'COONTADDRESS for this site. 1 <br /> also certify that all information provided on this application is true and correct;and that all regulated activities will he performed <br /> in accordance with all applicable SAN JOAQUIN COUNTY Ordinance Codes and/or Standards and S'I'A7'E and/or FEDERAL Laws <br /> and Regulations. <br /> APFUCANT NAME(Flaose PMI) <br /> SIGNA(NRREE <br /> 'tCUJ -j IeA ) %� < <br /> J ' <br /> MIX �q <br /> IpHPE000PYRFCGID1o) <br /> Approved BY DOfe Accounting Omce ProceylnQ ComPlaled By <br /> Dale/a � <br />