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May 19 OS 10: 09a F. 1 <br /> SAN JOAQUIN COUNTT ENVIRONMENTAL HEALTH DEPARTMENT <br /> MASTERFILE RECORD INFORMATION FORM <br /> 5/MD®SET7TDNSFORENO UsEOw.r amen lD it cases <br /> OWNER FILE <br /> COMPLETE THE FOLLOWWG BUSINESS OWNER INFORMATTON: CHECKIF OWNER CURREN7LY0AfMLr TH D <br /> BUSINESS rJ-.' F ^,LI L�� PHOII,ONE <br /> AM <br /> OWNER NE Rnt NI wr -3.SI-0900 <br /> BDSINFc`:NAME Iu�AAsrndrrowrertume) Sac See or Tau lDi <br /> Rl I -r s' -D4-`/% 73/ <br /> OWNER HOME ADDRESS q mpriumefit Aveywif. <br /> p�T�'Y R-P Ct�w10 N.fl $TALE ZJP 23�3 0 <br /> OWNER mA•ca0 An0R6ss Dt Wariastnarn Omer Adw.C) a�aaeN arGn of -- <br /> . 0 . 13ox ;�--7A0S <br /> MAIUROAOGWSSCm �i t+M OAI.p .FT zr o��o <br /> Type OP OwNe mll <br /> ODRPDnATION INOMDIIAL❑ PARTNER6fW LOCAL AGENCY❑ COUNTYAGENCYO STATEAtGENCY❑ FEDAEENCY QTNc'R❑ <br /> FACILITY FILE <br /> FAQUW ID N. co-0wNet ID C: Acc W NT ID A: <br /> OMPLETF THEFOLLOw7NG BUSINESS FACILITY&eQRMAnqN., <br /> Is th'r a mm eozhum L.DDATIGN or VEHICLE not PMV.oWy mp4 lad by ft ENW10Ns1F3rT, HEALTH DEPARTMEN" Yes ❑ No <br /> b thio en ElUS1WG Basin ss LOCA but a NEW TYPE of MgU10WO Bu 1? YEs ❑ NO <br /> BUSLNESSIFACILBY NAME Ma*1 W are av -OkWW M HEALTH PEHUM CAP-PEkrrEP- On . <br /> FAQLm ADDRESS(IfFAanr4 a MoatF00oUN4wF000 l9aaR uNr�ul. A'.e) Flus" 55 PHONE <br /> I?100 Sr !-�A�PA-n) ►�v1�FD, -Qg�- 800 <br /> QTY PIRraarN a AlomXFDaa Lwow Poco UoaafUse"wr.,c1l 3T C 7JR 330 <br /> �P <br /> Bt OFSUPERV&CRDIST LOCATION CODE KEY1 KUY2 <br /> AIMING AooR for Health FennitPl DIFFFREN76om Fad*,AdnefN Mission nrCm Of <br /> IsINIJHD ADDRE95Gm $TATE ZIP <br /> Sic Looe APK GOIINeR: <br /> rrnlnYrennwcc-0,or fees and charges: OWNER ❑ FACIUTY/BUSINESS <br /> Ru 7 Nc y rnwr.ANrr Ar MXTXMC N ' 1, abc undersigned Appliant,certify that I am the Owner Opprrnfor�or, Apih`or ad Agent this <br /> Business,and I ackAowIadee that Ill PEMIT FEET,PE T=,Et FORCVfEHT CRARGQ and/or HUURLY GYDue wast]' mmu wUn uw opermon»dI he <br /> ..L..aA .A 6N d.F—,u the ArmrmrADUREc4 fnrlTt,his site I also certify ther all infomtation Dtmi&A on this sppl=tion.s true <br /> F <br /> f�a <br /> Y IyIY '�1 �Y <br />