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SAN.IOAGUIN COUNTY PUMIC IIFAh II SLIIVICU -ENVIIIONMI'N I AI. III ALI II DIVISION <br /> r MASTERFILOECORD INFORMATIO <br /> TI I ' Under Conntmcliml <br /> ff.w 1TnTt <br /> 17.0.1y _ <br /> $//AJIED SECTIONSy FOR LO/CIII q W61 <br /> USE ONLY OWNER FILE INFORM TI <br /> DWNC-R ID /F --( I� CASE .–CK-H�C.Jf OWNER ON FItF <br /> Pleese ccomplete the following facility OWNER Information: 5 <br /> k Dwnnr nm .._ - <br /> TirNACo eP <br /> � ruein n Phone <br /> OwneDRA(fDIFFERENTfomOwn.r awl <br /> 0 - <br /> Own., <br /> "Owner Addrene <br /> ONE T AIV tD NT�� <br /> CITY Slnle Zip <br /> FO LT W oLTH TX 1(a I OZ <br /> Melling Add.... <br /> if DIFFERENT hem Owner Adrbese <br /> Cnre Of.r Attention <br /> lnptinrrnll <br /> Meiling Add.... City Stnln ZiP <br /> nuAinene <br /> coli; =I Type of Owen,6uolnnnn <br /> FACILITY FILE INFORMATION <br /> FACILITY ID # I / o II r AC000Nf ID /E <br /> Plense complete life following FACILITY information: <br /> Fnoilitylnor,innx Name(TNe wN be Nam.on Health PennifJ <br /> FncilitY Add,na. fit Fnciliry ie a Mobile Food Unit or Vehicles-Sen hnlowl Bnninene Phone <br /> r: I443 NAVY bf-tvE 209 - 9�P- o94q <br /> City <br /> Slnln Zip 95 26� <br /> TOC�T61J CA <br /> Criisu^- /nett �D or Surrovison Dlsmic* Loc�liou Con[" <br /> Mailing Addre..Ifer lleaah Parnell <br /> if DIFFERENT Fmm Fecifily Address ` <br /> Cern Of or Attention <br /> (oPfiennll <br /> Meiling Add,.. City Sint. Zip <br /> SIC C0,11 31 ^L II—jet rneilitY Sinhw Coll" I Gon.tel type of Buainnle�n nt thie MA� Bunineea Code <br /> l0 lnnnlion ppw�EY <br /> Bunlanan Typn. <br /> Piease complete U1c tollovymg irlommUlon if Corel Liss or U eroUon Location (such as Fair or festival/ is ditlormrt IFO <br /> Foalilr-fldd s r�+ 'A L� <br /> 71 <br /> FkA- <br /> . <br /> Nnme �, <br /> f Operation o ' E � Qvv -1–e47� C � / og55 <br /> St.te L[OZZiipV' TWALNv-r LSF C7nnrrno or!"u"r iurenn DIn1111CT - LOCATION COOr <br /> ll Invoices for Permit and Service FEES to: (Circle one OWNER'- FACILITY/BUSINESS <br /> A PROGRAM {EH U1 15b} ar WATER SYSTEM {EFl U1 15c} form must be complet—te for each 1 Envoonmentol FleBl <br /> regulated operation at this LOCATION except UST Program (Use SWRCB forms) <br /> u�ra,�rr6c— <br />