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REV. 04/09/99 <br />SAN JOAQUIN COUNTY "UBLIC HEALTH SERVICES S ENVIRONMEN' 4EALTH DIVISION <br />MASTERFILE RE40RD INIKAMATION <br />DATE OWNER 10 Y CASE Y <br />OWNER FILE <br />CHECKIF OWNER CURRENTLY ON FIIF wrrn EHO <br />COMPLETE THE FOLLOVVING BUSINESS OWNER INFORMATION; El <br />SLSINESS OWNER NAME <br />BL.SAESS/FACIUTY NAME (THIS WILL SE rHE NAti1E ON THE HEALTH PERMIT) <br />" <br />/� 1 <br />_C <br />' <br />sun sun Y <br />PHONE <br />77 .7-7 , q <br />ZU P— — <br />D O IJ <br />L <br />i <br />Oq _ <br />LOD1 <br />rS1 <br />A41a5f <br />BOARO Of SuKiri Oa DISTRICT LOCATION CODE <br />KEYI <br />BLbINESS NAME (# DIFFERENT from Business Noma) <br />SOC SEC / TAX ID Y <br />C) Q —ID <br />Moiling Address City <br />STAR <br />ZIP51C <br />CODE <br />OWNER HOME ADDRESS <br />COMMENT <br />Gty I <br />STATE <br />zip <br />aliLo r• <br />OWNER MAILNGADDRESA- IFFERENT ft. Owne(A ess) <br />Attention:of Cate o( (OpNonoO <br />Mating Address City <br />State ZIP <br />(_]/ <br />TYPE OF OWNERSHIP' <br />CORPORATION t <br />INDIVIDUAL <br />PARTNERSHIP <br />LOCAL AGENCY <br />COUNTY AGENCY STATE AGENCY FED AGENCY It OTHER III <br />�1 <br />1 FACILITY FILE <br />FACILITY ID # Do L 13 CROSS REF IDx ACCOUNT ID # <br />i-nAADI rTr TWr rn) I nW1Nr RI ICINESS PA(—Il ITY INFORMATION' <br />' ACCOUNTADORE55 for fees and charges OWNER / FACILITY/BUSINESS i <br />BILLING AND COMPLIANCE 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, PENALTIES, ENFORCEMENT CliARGES and/or HOURLY <br />CHARGES associated Nvith this operation will be billed to me at the address identified above as the ACCOUNTAUURF:SS 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. Z <br />APPLICANT NAME (Please Print) <br />TITLE <br />Approved By Dote Accounting Office Processing Completed By I l Date <br />BL.SAESS/FACIUTY NAME (THIS WILL SE rHE NAti1E ON THE HEALTH PERMIT) <br />" <br />/� 1 <br />_C <br />FACILITY ADORESS OR COMMISSARY ADDRESS <br />sun sun Y <br />BUSINESS PHONE <br />c�1. Z -7 70 <br />ZU P— — <br />Cm OR COMMISSARY ADORESS <br />STATE <br />C►`, <br />LP <br />Q�"Z v <br />LOD1 <br />BOARO Of SuKiri Oa DISTRICT LOCATION CODE <br />KEYI <br />KEY2 <br />HEALTH PERMIT MAIUNG ADDRESS ( H DIFFERENT hon Fociaty Address) <br />AMentiol: or COTe Of (010110n00 <br />Moiling Address City <br />STAR <br />ZIP51C <br />CODE <br />"N <br />COMMENT <br />' ACCOUNTADORE55 for fees and charges OWNER / FACILITY/BUSINESS i <br />BILLING AND COMPLIANCE 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, PENALTIES, ENFORCEMENT CliARGES and/or HOURLY <br />CHARGES associated Nvith this operation will be billed to me at the address identified above as the ACCOUNTAUURF:SS 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. Z <br />APPLICANT NAME (Please Print) <br />TITLE <br />Approved By Dote Accounting Office Processing Completed By I l Date <br />