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REV. 04/09/99 <br /> SAN JOAQUIN COUNTY UBLIC HEALTH SERVICES 8 ENVIRONMEN EALTH DIVISION <br /> �-��� NIASTERFILE RECORtrINFORMATION - <br /> ('j ` pwxF310 I ��I��/ CAFE 3 <br /> DATEG(IbIO` v <br /> OWNER FILE CeECYIF OWNERCUMN11YOWILIMMEHD El <br /> THE FOLLOWING BUSINESS OWNER INFORMATION: <br /> r✓S: �f 35f <br /> SOC SFC/iA%IDY <br /> &sxEct NAVE If OIPFSREMbom(iusi+asi NOma� '+ e�. W ... <br /> OYRLLR HOhffA•'CiEss // rj h �S TUI Lr30E6 <br /> ay GL T 7 b <br /> AM1anFan uCua d (optlCM-0 <br /> OYm[a FIAue Axi`-ss (YOfffEREPR Rem OwnelAWresE) . <br /> Stria aP <br /> Nlwing ACGau Gy <br /> VKUOwraSs+u. <br /> CORPORARON[ INOIVIOUAL PARTNERSHIP LOCAL AGENCY COUPfrY AGENCY STATE AGENCY FEO AGENCY O1HER t <br /> FACILITY FILE <br /> CROSS RFF lO ACCOUNT ID M /YN <br /> FACILITY ID b <br /> COMPLETETHEFOLLOWING BUSINESS FACILITY INFORMATION: <br /> ifux(ssfFAr'�un NAu[(ixuvnu aE M[)it,1E,On TH HEAIM PERt.IR) �1 ,� <br /> III 1!/- S�frtr &-cuss Pnoxi <br /> FAcvr.Amiss aacunrcsuvAmxss Z��/�t/' g7— 665-6 <br /> CM Ca CGh3.l,StllT.V.OR.SE „ / nA�C.� LP ( <br /> J5 `-�IS-- - <br /> LC TCW <br /> gow-:UXrErreGa OSaeE AItx+Yon:u CuB 01(WH�rnO <br /> HEALTH PfRAIn r.IAMIG AOORESS L N WFERENT FOCLy AWrasE) <br /> $TAR�/Azar <br /> F1dIlnO ACCreu Oy <br /> CU.mwl <br /> SIC C=( APN <br /> NER FACILITY/BUSINESS <br /> Aeepur!teLooacss lar leas and chofgas . <br /> BILLING AND COIIIPI.I.NNCE ACRN0IVI.F0GAIENT: I, the undersig Applicant, certify that I am the Owner, Operator, or <br /> at <br /> ERMIT FEP'S, <br /> Authorized Agent of this AL- <br /> CHARGE'S aS5UL'IatCll U'lI11B11111ess and U[ICrahl)nll4tl be billc 1 tolme atiN a address identified atbove as the A'cCou URt'ss for this ENT CIIAKGES �tell <br /> also Certify tllat all information provided oil this application is true'and Correct;and that all regulated aL'tI and/ r ED RACL Laws <br /> in accordance with all applicable SAN JD.4QUIN COULNY Ordinance Codes and/or Standards and STATE and/or FEDERAL Layrs <br /> and Regulations. <br /> SIGNATURE <br /> "FUCA NA IE 01m PMI) <br /> °I fdc£bl�-I.6tw <br /> TIRE <br /> Dcle <br /> ACCOVOMO OMC'PIOCa61InQ <br /> OOT. CunFIetRO 0y : <br /> A;gra•ad BY ' <br />