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SAN JOAQUIN COUNTY ► PUBLIC HEALT14 SERVICES • ENVIRONMENTAL 1#EALTH JIIVIsiok •.- <br /> DATE MASTERFILE RECORD INFORMATION ' tEnoa,ssa �orseroF <br /> OVIINER FILE ' <br /> COMPLETE TMEFOLLOWINQBUSINESS OWNER INFORMATION: CWffcww OWNER CuPrx wT rcw~owmEHa <br /> "Alm _ -- <br /> — — —�► —r.�-------- <br /> 11UNNI ss NAM pf&W rs 1*00 0wrrrr Nacre) Soo Sea ITAX m o <br /> ' Orals HorE AnwEss <br /> Cft1 STATE zR <br /> 1 <br /> OwM MAa.mftaam NOErt7rERElYrAlan glwrtirAddnrr AWwtlwu arCars of.(aprwra/J <br /> 1 <br /> Metlirq Addr+sa aty $cal. zip <br /> Tm er Owpo sew. <br /> Tian c3 ❑ ❑ ❑ E3 11616- 0 ❑ C <br /> FACILITY FILE <br /> `, ..........,•o-r.::::::::::3ke#:9 '>3ef?e:::3eieeixi#.:.:M}ic:;::.. 3e",�,i•. :#"E�Ei <br /> COMPLETE TNE.FOLLOWINO BUSINESS FACILITY INFORMATION: <br /> Is clan a New Buoys LmAnm or Velww not prwgiouwy repubted b!/the EwAnowmff u.WALT"ExV ew"4 Yes ❑ No ❑ <br /> Is u*an Emaym Business LocATIM but a New r n of rsQuisted Buelnese T Yes ❑ No ❑ <br /> Bus@enw=Lw MAw(Twom sE TSE NAreau HEARTH PERM) <br /> :w sFACXMAoM(*FAr�uWWAAbsas•F0WUNrQVF0WMYa ELW 8u1TeS BusslE►sPi+oNE <br /> ase <br /> GTrAtFAaurrwAJfasaeFo=L4wraw#rbW 0740LEW STATE Zr <br /> MaMrrS Addr+se Aar Y P.raMI NOI�FE VTIIonr FiraAll AafrAwe RE�1 Ail m&m:a Cam Of(OPEORO) <br /> Maw Address city STATE zr <br /> :NODx <br /> TNIRO PARTY BILLING INFORMATION: _ ea*e Il Blllina Part /s dlfliri-ent from Business Owns;/denllM d above <br /> SrnraTa NAre ..... <br /> I.Aftmilm erCara Of(opdrarrslJ <br /> MalrltO PROW <br /> QA t STATE z <br /> tlF( Fl d for toes and ohwo" OWNS ❑ FACLr YIBUWMS 13THOW PARIY bLLNG ❑ <br /> BIt.1.tNEi AND COMt■I.tANCIt ActCNQw_� ueMlsNT: 1,the undersigned Applicant,certify tha f I am the Owner, Operator,or Author$ <br /> LMG <br /> Agent of this Business, and I Acknowledge that All P"Urr FEas, PLrNAL719S, ENFORCE1IlM " CHARG a�sd/or-NoUlt 1 aa t:lso cerccerti <br /> associated with this operation will be billed to me at the address identified above as the AccrovMAObR for this site <br /> that all Information provided so this application Is true And correM; and that all regulated activities will be performed <br /> accordance with all applicable SAN JOAQUIN COUNTY Ordinance Codd and/or Standards and STATS and/or FEDIMAL Lays ar <br /> ReguIStions. <br /> PiEASE Psp" <br /> APPLICANT MANE SNiNi►riME . <br /> TITLE MtiVER'S t ICEN$E/ <br /> moToaorr seouraeol ,,,,, ,,,,,r <br /> x• .<;. <br /> . '33': •#:: :5:: :::i:i^ issi:is::Eii:9eE#iY:i <br /> :'%:»•#a:d7 :::d: `:77: a:R:7:f itiir'� ::.:: i�111;M��::i::::::•::cic:::::::: :•:::::•::::. <br /> x�poiiiinlliro:pitlasP.ioi� +siigi; j• .s.•;>• ..:..... <br />