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PW <br /> REV. 04!09!99 E� <br /> r <br /> SAN .JOAQUIN COUNTY i1 r'UBLIC HEALTH SERVICES,8 ENVIRONMENTWEALTH DIVISION <br /> NIASTERFILE RECORD'INFORMATION <br /> DATE 0,H""I01 D, \Ovll�}� / CASES <br /> OWNER FILE <br /> cXE<KV own=.RcuavEvnrownEEWITH EHO <br /> COMPLETE THE FOLLOWING BUSINESS OWNER INFORMATION: <br /> Bu;r,Ess owuR w+rt 01' lGa bow PnaE,E 9�-S 4 0`flf <br /> JSI <br /> &Se,[Y NAME(YDIffEREM hom Buwuv Nama) <br /> J+�- " <br /> aIkA <br /> OwHIR HOI.,f ARCaSS � � <br /> OwWRFIu:+G A'X�=ss (YOIFfFRFMrtem OwnarAWress) / Anan :aeeraof (opNane7 <br /> Nldling ACNeu Gp (G.•`•—q�wCi Slde Lp <br /> has OwnE4sr✓a ' <br /> CORPORATION[ INDIVIDUAL TN <br /> PARERSHIP LOCALAGENCY COUNNAGENCYif STATE AGENCY III FED AGENCY 4k OTHER 2i <br /> FACILITY FILE <br /> FACILITY ID If l V Vj <br /> cc77 <br /> nng4?jq CROSS REF IOY ACCOUNT IDp 251 <br /> t <br /> COMPLETETHEFOLLOWING BUSINESS FACILITY INFORMATION: <br /> &srau/FACm NAVE(Tr.uvau M f NAeIE On ME HEALTH KPP.fr) <br /> J A Lt O_C <br /> Fwcnm Aoaass ox ccA,M¢wvAoaau $UfEY &srlss HghE <br /> a_o8'LL <br /> cm eeconunwvAnaass� \ ss/r.� LY q, <br /> cP� C/Y1 ( S�oZ <br />' g]ARp Cf$l:a2rt'CADuan LOGroN CORE KEPI KF1Z <br /> All n?q :w Care a(opfbno0 <br /> HEALM FERAIff MAILING ADDRESS(YDIffEREM hwn frLry AtlCrav) <br /> SAM 7Y <br /> Mdllnq Aad,Ou Clty � <br /> SIC CM APN CCMMEM <br /> ACCOU11TA00RERF forfees and charges OWNER FACILITY/BUSINESS <br /> BILLING AND COMPLIANCE ACKNOwI.F.DGNIENT: I, the undersigned Applicant, certify that I am the Ow/ler, Operator, or <br /> A)ithori.ed Agent of this Business,and 1 acknowledge that all PERMIT FEES,PENrILTIEs,E.YFORCEMENT CIIARQES and/or 110URLr <br /> C11ARGES associated with this operation will be billed to me at the address identified above as the ACCOUhTAb0RF.55 for this site. I <br /> also cerliry 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 S'I'A7'E and/or FEDERAL Laws <br /> and Regulations. <br /> SIGNANRE <br /> APP CANT NMIE(Hoare Print) <br /> MUM '(v nfOtOVItt ��o) <br /> App ed 8y D f <br /> —� A< austl OOtA P esiln9 CompteteE By ���._ Data <br />